Form Travel Card – Fill Out and Use This PDF

The Travel Card form is specifically designed for Department of Defense employees seeking to set up an Individually Billed Account through the Citibank® Government Travel Card Program. This comprehensive form requires the completion and approvals from the employee, their supervising officer, and the Agency Program Coordinator (APC) to ensure adherence to privacy and policy guidelines, including the Privacy Act of 1974. Ready to streamline your travel expenses? Click the button below to fill out your Travel Card form.

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Form Travel Card PDF Details

The Individually Billed Account Travel Card Set Up Form, facilitated through the Citibank® Government Travel Card Program, is a critical step for Department of Defense employees seeking a new travel card account. This detailed form requires careful completion by the employee, the approving supervisor, and the Agency Program Coordinator (APC), encompassing a wide range of information governed by the Privacy Act of 1974 and relevant agency regulations. Essential sections cover reporting parameters, cardholder information, including personal and contact details, and various consents and agreements regarding the handling and processing of the account. Notably, the form addresses significant compliance and security measures like identity verification in line with the U.S.A. PATRIOT Act, underscoring the federal government's efforts against terrorism and money laundering. Applicants are presented with options for paper-free billing and express delivery, alongside instructions on consent for mobile contact and electronic statement delivery, ensuring that the process caters to modern convenience while adhering to strict security standards. This comprehensive approach ensures that all necessary details are meticulously collected and handled in accordance with federal laws and guidelines, demonstrating the intricate balance between user convenience, security, and regulatory compliance in the process of issuing a government travel card.

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Form Name	Form Travel Card
Form Length	6 pages
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Avg. time to fill out	1 min 30 sec
Other names	citibank government travel card fillable forms, form travel card, travel discount card, what account can you fund and withdraw interest

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Individually Billed Account Travel Card Set Up Form

Citibank® Government Travel Card Program

Instructions:

This form must be completed by the Department of Defense employee, approving supervisor and the Agency Program Coordinator (APC). Use this form to apply for a new Individually Billed Card Account to be used by a Department of Defense employee. Information collected on this application is subject to the Privacy Act of 1974 (5 U.S.C. 552a) and applicable agency regulations. Questions? Contact Commercial Card Services toll-free 1-800-200-7056 from the U.S. and Canada or, if dialing from international locations, call 757-852-9076.

See pages 4-6 for detailed instructions on completing this form.

Contains personally identifable information (PII) and should be handled in accordance with Federal and DoD Privacy Act Policy guidance.

Fax: 866-671-5910 605-338-5745

Section I: Reporting Parameters (To be completed by APC. * = Required felds)

1.Citi Account Hierarchy*

Specify the complete 7-digit account Hierarchy Level (HL) numbers that pertain to your organization. Each Hierarchy Level consists of 7 digits.

HL1

HL2

HL3

HL4

HL5

HL6

HL7

HL8

Section IIa: Cardholder Information (To be completed by employee. * = Required felds)

2.Applicant Name*

Provide full name: First, Middle Initial and Last name of the applicant as it should appear on the card (maximum of 25 characters — including spaces)

3. Applicant SSN*

–

4.Date of Birth* (mm/dd/yyyy)

5.Applicant Address Details*

Address must be U.S., U.S. territory, APO/FPO/DPO. Application will not be processed if a foreign address is provided.

If your Primary Address is a P.O. Box, please complete the Home/Physical Address section below. If your card should be mailed to an alternate address, please complete the Alternate Address section below and check the Ship Card to Alternate Address box. Applications providing only a P.O. Box will not be processed; a physical address is required. For APO/FPO/ DPO addresses only, a physical address is not required. For Expedited Card Delivery a physical address is required in Primary or Alternate Address section. Please note: for expedited cards, a signature is required at time of delivery.

□Expedited Card Delivery □ Ship Card to Alternate Address (One Time Mailing)

Primary Address* (this is where your statement will be mailed)

Mail to Attention

Address Line 1*

Address Line 2

Address Line 3
City or APO/
FPO/DPO*
State*	Zip/Postal Code*	–	Country
State*	(Last 4 digits optional)	–	Country

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Section IIa: Cardholder Information (Continued)

5.Applicant Address Details*

Home/Physical Address* (No Post Offce Box)

Mail to Attention

Address Line 1*

Address Line 2

Address Line 3
City or
APO/FPO/DPO*
State*	Zip/Postal Code*	–	Country
State*	(Last 4 digits optional)	–	Country

Alternate Address (One Time Mailing)

Mail to Attention

Address Line 1*

Address Line 2

Address Line 3

City or

APO/FPO/DPO*

State*	Zip/Postal Code*	–	Country
	(Last 4 digits optional)

6.Applicant E-mail Address* Contact

Details*

Business Offce Phone*

Business Extension

Primary Phone*

□ Mobile

Secondary Phone

□ Mobile

□ Home

7. Employee ID*

10 digit number found on the back of the DoD issued CAC card.

Section IIb: Cardholder Information (To be completed by employee.)

8. Mobile

If you provide or have provided us with a mobile number or number later converted to a mobile number, you agree that

Phone

Citibank or our service providers may contact you at that number about your Commercial Card account. This consent

Consent

allows us to use text messages, automated voice messages and automated dialing technology for informational and

account service calls but not telemarketing calls. Message and data rates may apply. Opt out at any time by sending an

email to optoutcellconsent@citi.com

9.Paper-free You have the option to receive your card account billing statement (“statement”) electronically and certain notices,

Option	including legal notices, for your card account (“notices”) electronically. If you select this option, your statement as well as
	any notices that we make available electronically now or in the future will be available to you for viewing and printing on the
	CitiManager web site and will not be mailed to you. We will send you an e-mail alert to the e-mail address provided above
	when your statement or a notice is available. If you wish to select this option, please check the box below:
	□ By checking this box, I agree to receive statements and notices electronically as described above and to receive e-mail
	alerts of statements and notices. I understand that I must register for CitiManager at www.citimanager.com/login in
	order to view statements and notices electronically.

Citi Transaction Services
© 2021 Citibank, N.A. All rights reserved. Citi and Arc Design are registered service marks of Citigroup Inc.
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Section IIb: Cardholder Information (Continued)

10. Ohio	OHIO RESIDENTS: The Ohio laws against discrimination require that all creditors make credit equally available to all credit
Residents	worthy customers and that credit reporting agencies maintain separate credit histories on each individual upon request.
	The Ohio civil rights commission administers compliance with this law.

11.New York NEW YORK RESIDENTS: New York residents may contact the New York State Department of Financial Services by

Residents telephone or visit its website for free information on comparative credit card rates, fees and grace periods. NY State Dept of Financial Services: 1-800-342-3736 or visiting www.dfs.ny.gov

Section III: Cardholder Signature & Agreement (To be completed by employee. * = Required felds)

Signature & Agreement*

By signing below, I: (i) acknowledge I have read the Citi® Cardholder Agreement; (ii) agree to be bound by the terms and conditions as set forth in the Agreement; and (iii) understand that only the Department of Defense may request particular Authorization Parameters (Section III). This application is for a Department of Defense Travel Card account, which may be standard or restricted, as described in the Cardholder Agreement. I expressly agree to accept whichever type of account is established. Pursuant to requirements of law, including the U.S.A. PATRIOT ACT, the bank is required to request additional information to verify your identity.

IMPORTANT INFORMATION about opening a new Citibank® Travel Card account: To help the United States Government fght terrorism and money laundering, Federal law requires us or your employer to obtain, verify, and record information that identifes each person that opens an account. What this means for you: when you open an account, we or your employer will ask for your name, a street address, date of birth, and an identifcation number, such as a Social Security Number, that Federal law requires us or your employer to obtain. We or your employer may also ask to see your driver’s license or other identifying documents that will allow us or your employer to identify you. Citi will not accept military identifcation cards or government badges as an acceptable form of identifcation. We appreciate your cooperation.

12. Applicant’s Signature*

13. Date*	/	/
(mm/dd/yyyy)	/	/
(mm/dd/yyyy)

Section III: Cardholder Signature & Agreement (To be completed by employee. * = Required felds) (Continued)

Signature & Agreement*

14. Credit Score

A. □ ________ I, as the cardholder,

B. □ ________ I, as the cardholder, DO NOT authorize

Authorization*

authorize the bank to obtain my credit

the bank to obtain my credit score. Therefore, I

(INITIAL ONE*)

score as described in the agreement.

have completed and submitted an alternate credit

worthiness assessment (DD Form 2883), and

understand I will not be eligible for a standard card.

15. Approving Supervisor’s Signature*

16. Date*

(mm/dd/yyyy)

Section IV: Authorization (To be completed by APC. * = Required felds)

17.Authorized APC*

By signing below, I hereby authorize, on behalf of the Agency/Organization indicated above, that a Department of Defense Travel Card be issued to the employee named in Section I of this application. PLEASE RETAIN A COPY FOR YOUR RECORDS.

APC Name (type or print)*

E-mail Address*

APC Signature*

Date*

(mm/dd/yyyy)

Commercial Offce

(

)

Phone*

Citi Transaction Services

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Instructions Sheet — Supplement to Cardholder Application

IMPORTANT INFORMATION about opening a new Citi® Department of Defense Travel Card account:

To help the United States Government fght terrorism and money laundering, Federal law requires us to obtain, verify, and record information that identifes each person that opens an account. What this means for you: When you open an account, we will ask for your name, a street address, date of birth, and an identifcation number, such as a Social Security Number, that Federal law requires us to obtain. We may also ask to see your driver’s license or other identifying documents that will allow us to identify you. Citi will not accept military identifcation cards or government badges as an acceptable form of identifcation. We appreciate your cooperation.

Please maintain copies in the Cardholder and Agency Program Coordinator’s fles.

Purpose:	Complete this form to apply for an individually billed cardholder travel card account for a Department of Defense employee.
	This form should only be used to request the opening of a new account for a new cardholder.

Instructions:	Who: Cardholders: This form is only to be used to open a new account. Fill out Section IIa: Cardholder Information, Section
	IIb: Mobile Phone Consent, Paper-Free Option and Section III: Cardholder Signature & Agreement, items 8, 9, 10, 11.
	Please print or type all information. Required felds are identifed by asterisk (*). Incomplete applications will not be
	processed and may be returned at the direction of DTMO Travel Card Program Management Offce.
	Approving Supervisor: Complete Section III, items 13, 14. This form is only to be used to open a new account. Please
	provide your signature and the date signed. Required felds are identifed by asterisk (*). Incomplete applications will
	not be processed and may be returned at the direction of the DTMO Travel Card Management Offce.
	APCs: Complete Section I and IV. This form is only to be used to open a new account. Please print or type all
	information. Required felds are identifed by asterisk (*). Incomplete applications will not be processed and may be
	returned at the direction of the DTMO Travel Card Management Offce.

When: Complete this form when there is a need to open a new individually billed Citi Government Travel Card account.

How: Section I: Reporting Parameters

(To be completed by an APC)

1.Citi Account Hierarchy (required): The Citi hierarchy unit number under which the new account will be established. Complete as many hierarchical levels as are appropriate for your organization. Each level of hierarchy consists of a seven-digit number; up to eight levels of hierarchy may be assigned. Citi hierarchy levels are sequential and indicate the organization’s pedigree as illustrated in the EXAMPLE below:

HL1 = Department of Defense

HL2 = Branch of Military Service or DoD Independent Agencies HL3 = Major Command or individual DoD Agency name

Etc.

A complete hierarchy level number always begins with Level 1 and contains successive level numbers, down to the lowest level assigned. It is required to determine the reporting group to which a cardholder’s account will belong.

Section IIa: Cardholder Information

(This section to be completed by Department of Defense Employee)

2.Applicant Name (required): Print or type the frst, middle (if applicable) and last name of the applicant (maximum of 25 characters including spaces).

3.Applicant SSN (Social Security Number) (required): Enter the employee’s Social Security Number. The accuracy of the SSN is critical for split disbursement payments to be posted accurately and timely to the card account.

4.Date of Birth (required): Enter the date of birth for the individual applying for the card in mm/dd/yyyy

format (example: 01/01/1973). Applicants must be 18 years of age or older.

(continued on next page)

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Section IIa: 5. Applicant Address Details (required):
(continued)	• Primary Address (required): Indicate the address to which the billing statements should be mailed

	(includes Street, City or APO/FPO/DPO, State/Province, Zip/Postal Code). Address must be U.S.,
	U.S. territory, APO/FPO/DPO. Application will be rejected if the address is outside of the card
	issuing country. This is also the address the card will be mailed to unless an Alternate Address is
	provided and the Ship Card to Alternate Address box is marked. If a P.O. Box is provided as the
	Primary Address, a Home/Physical Address must also be provided.
	Note: If indicating APO/FPO/DPO address, enter APO, FPO, or DPO in “City” feld; AE, etc.
	in “State” feld.

•Expedited Card Delivery: Indicate whether the card should be mailed within 2-3 business days.

A physical address must be provided for expedited card delivery. Please note: for expedited cards, a signature is required at time of delivery.

•Mail to Attention: Indicate the name of the individual to whom the new card should be mailed.

•Home/Physical Address: Complete this section if a P.O. Box is being provided as the Primary Address.

•Alternate Address: Complete this section if the card is being sent to an alternate address.

6.Applicant Contact Details:

•E-mail Address (required): Indicate the e-mail address of the individual applying for the card.

•Business Offce and/or Home Phone (required): Indicate the business and/or home phone numbers (including area code) of the individual applying for the card. For locations outside of the U.S., include the applicable two-to-three digit country code. Note: an international access code, such as “011,” is not required.

•Cell phone number: Indicate the cell phone number (including area code) of the individual applying for the card. For locations outside of the U.S., include the applicable two-to-three digit country code. Note: an international access code, such as “011,” is not required. If you provide or have provided us with a mobile number or number later converted to a mobile number, you agree that Citibank or our service providers may contact you at that number about your Commercial Card account. This consent allows us to use text messages, automated voice messages and automated dialing technology for informational and account service calls but not telemarketing calls. Message and data rates may apply. Opt out at any time by sending an email to optoutcellconsent@citi.com

7.Employee ID: Enter the 10-digit ID number as it appears on the back of your CAC card.

Section IIb: 8. Mobile Phone Consent 9. Paper-Free Option

(This section to be completed by Department of Defense Employee)

Check the box if you wish to receive statements and notices electronically on the CitiManager web site and to receive e-mail alerts of statements and notices. To do so, you will need to register for CitiManager at www.citimanager.com/login.

10.Ohio Residents

11.New York Residents

Section III: Cardholder Signature & Agreement

(This section to be completed by Department of Defense Employee)

12.Applicant’s Signature (required): The applicant’s signature. Wet or Digital signature accepted.

13.Date (required): Enter the date the applicant signed the application.

14.Credit Score Authorization (required): Applicant reads options A and B and places frst and last initials next to the option they agree to. Option A is a soft credit inquiry.

15.Approving Supervisor’s Signature (required): Signature of supervisor approving application. Wet or Digital signature accepted.

16.Date (required): Enter the date the supervisor signed the application.

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Section IV:

Authorization

(To be completed by APC)

17.Authorized APC (required): The name and contact information of the Agency/Organization Program Coordinator, for this applicant, completing this section of the setup/application form.

Required information includes:

•APC Name (type or print)*

•E-Mail Address (required): The APC’s e-mail address.

•Signature (required): The APC’s signature. Wet or Digital signature accepted.

•Date (required): The date the APC signed the application.

•Commercial Offce Phone: The APC’s commercially accessible business phone number, including the area code. For locations outside of the U.S., include the applicable two-digit to three-digit country code. An international access code, such as “011” is not required.

Submit the frst and second pages of the request form ONLY via mail or fax as follows:

Citibank. N.A.

P.O. Box 6408

Sioux Falls, SD 57117-6408

CONUS FAX number: 1-866-671-5910

OCONUS FAX number: 1-605-338-5745

Citi Transaction Services

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