XEROX CANADA LTD.

PURCHASING CARD APPLICATION

January 2011

SECTION I INSTRUCTIONS

Pre-Requisite:

1. S3 Logon Access is required to utilize the PCard system.

To Add New Account:

1. Select New Account request

2. Complete all fields on form

To change information for existing accounts:
1. Complete Section II with the type(s) of request. Complete only the applicable fields on the form that need to be updated.
2. Fill in the last s even digits of the individual Purchasing Card number.

3. Fill in card member’s name as it appears on their Purchasing Card.

Please send completed form to Program Administrator via:

** PRIOR TO SUBMITTING YOUR APPLICATION PLEASE LOG INTO THE P-CARD SYSTEM AND COMPLETE THE REGISTRATION PROCESS AT THE LINK BELOW. THIS IS COMPL E TED BY ENTERING THE “PROFILE” ICON, IF ASSISTANCE IS REQUIRED PLEASE VISIT THE P-CARD ON-LINE TRAINING AVAILABLE AT THIS SAME LINK: y.xerox.com/xeroxg1/training.jsp?country=CANPcard

*For all new requests, please attach a signed copy of the P-Card Employee Agreement. As well please make sure you and your approving manager have completed the P-card Acknowledgment course GP00014 prior to submitting your application.

Note: The address entered onto the form will be where the card and statements are to be mailed.

Your data will be stored and processed in whole or in part in the United States. If you proceed to fill out the Citibank Purchasing Card application, your data will be transferred out of Canada to the United States. Your information will be treated as confidential information and with the understanding that it may be used for any purposes necessary to process this application. Information provided on this application may be available to United States Government or its agencies under US law.

SECTION II TYPE OF REQUEST (“X” all applicable)

___ a. New Account _____ Card_____ No Card ___ e. Transaction Limit Adjustment- Please circle one

___ b. Address/Telephone Change (Permanent or Temporary)

___ c. Name Change

___ d. Re-Open Account

SECTION III CARDHOLDER INFORMATION

_____________________________________________________________________________________ (______)__________________________

First Name of Cardholder Middle Initial Last Name (max. 25 char) Business Phone

Xerox Canada Ltd.

_______________________________________________________________________________________________________________________

4th Line Embossing (max. 24 char) Date of Hire (mm/yyyy) Date of Birth (mm/dd/yyyy) Employee #

______________________________________________________________________________________________________________________

Business Address (max. 36 char) Suite

______________________________________________________________________________________________________________________

City Province Postal Code

SECTION VI TRANSACTION LIMITS

Monthly Limit $ _6,650.00____________ Single Dollar Transaction Limit $ _3,000.00 _____________

EXCEPTION LIMITS

Monthly Limit $ _____________ Single Dollar Transaction Limit $ ______________

*Any adjustments or exceptions to these limits should be provided to the program administrator by the manager of the cardholder.

SECTION VII

I, the cardholder, acknowledge that upon use of my card, I agree to abide by the procedures established in the Xerox Purchasing Card Employee Agreement. I understand that it is my responsibility to notify Citibank at 1-800-248-4553 immediately if my card is lost or stolen.

Cardholder Signature Date:

Manager Signature Date:

Comments:

Finance VP Signature______________________________________________________________________________________________ Date: ______________

Xerox Purchasing Card Employee Agreement

The Xerox Purchasing Card Program is intended to allow authorized employees to make business related purchases utilizing the Citibank MasterCard Purchasing Card. Your acknowledgement and signature below is verification that you have read the purchasing card training documents and that you understand, agree with and will adhere to the policies and procedures that govern the Purchasing Card Program and the statements outlined below.

1. I understand that the purchasing card is for Xerox approved purchases only, and I agree not to make personal purchases.

2. Improper use of this purchasing card will be considered misappropriation of Xerox funds. This will result in disciplinary action, up to and including termination.

3. If the purchasing card is lost or stolen, I will immediately notify Citibank by telephone. I will confirm the telephone call by e-mail or fax along with a copy of the notification to the Xerox Purchasing Card Administrator.

4. I agree to surrender the purchasing card immediately upon termination of employment, whether for retirement, voluntary or involuntary reasons.

5. All charges will be billed to and paid directly by Xerox. The bank cannot accept any monies from me directly; therefore, any personal charges billed to the Company will be considered misappropriation of Xerox funds and could result in disciplinary action, up to and including termination.

6. Any charges for personal use or other use by me in contravention of this Employee Agreement or the policies and procedures that govern the Purchasing Card Program must be reimbursed to Xerox in the form of a personal check, money order or cashier check.

7. As the purchasing card is Xerox property, I understand that I will be required to comply with internal control procedures designed to protect Company assets. This includes producing the purchasing card to validate its existence and account number. I am also responsible to review/approve all transactions and will be asked to provide receipts and statements for audit purposes.

8. I will receive a Monthly Reconciliation Statement, which will report all purchasing card activity during the statement period. Because I am responsible for verifying all charges on the purchasing card, I will resolve any discrepancies by contacting the supplier first with elevation to the bank.

9. I understand the purchasing card is assigned to me as a Xerox employee based on a need to purchase materials for the business. My purchasing card may be revoked based on change of assignment or location. I understand that the purchasing card is not an entitlement nor reflective of title or position.

______________________________________ ___________________________________

Employee Signature Approving Manager Signature

_____________________________________ ___________________________________

Employee Printed Name Approving Manager Printed Name

Employee Number:_____________________ Employee Number:____________________

_____________________________________ ___________________________________

Date Date