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TERMS OF REVOCATION FORM <br /> 1 <br /> As an authorized user of the MasterCard Purchase Card, I understand that I am the only person authorized <br /> to make purchases with the Purchase Card issued to me and that such purchases must be in connection <br /> with my employment with, for the benefit of, and authorized by (fill in district name). <br /> 1 understand that the following items constitute misuse of the MasterCard Purchase Card and that any <br /> misuse will result in the revocation of my privileges to be a MasterCard Purchase Cardholder, and may <br /> result in revocation of all departmental and/or divisional Purchase Card privileges. <br /> Misuse of the MasterCard Purchase Card includes the following: <br /> ® Using the MasterCard Purchase Card for personal purchases <br /> ® Purchase of unauthorized items <br /> ® Use of the Purchase by someone other than the cardholder <br /> ® Fraudulent or inaccurate record keeping <br /> If the MasterCard Purchase Card is used for personal purchases, for unauthorized items or by someone <br /> other than myself, I hereby agree to personally pay either City of Centerville or the vendor for such <br /> purchases and hereby authorize City of Centerville, if necessary, to withhold from my paycheck any <br /> amount necessary to pay these charges. <br /> Name of Cardholder Date <br /> (Please Print) <br /> Cardholder's Signature <br /> NOTE: In addition to the above consequences for misuse of the MasterCard Purchase Card, City of Centerville retains the <br /> right to take Rather action, whether in the form of disciplinary action, temtination of employment, and/or legal <br /> prosecution, in the event of gross misuse or fraud involving City of Centerville fiords. <br /> 16 <br />