Fill and Sign the Ma Dept of Housing and Community Development Resident Notice and Consent Form

Request For Corporate Card Reinstatement AMERICAN EXPRESS® CORPORATE SERVICES Completed application must be faxed (without a cover sheet) to (602) 744-8894 Applicant Information Name Date Submitted Cancelled Account # Social Security Number Home Address Billing Address NOTE: Requests for Reinstatement of Corporate Express Cash and/or Corporate Travelers Cheques are to be made by reapplying for Corporate Express Cash and/or Corporate Travelers Cheques separately. All information must be provided before processing can proceed. Application will not be processed if the account has been sent to an Outside Collection Agency or if the account has aged 180 days past due. Spending restrictions may be imposed if the account is reinstated. Home Telephone Business Telephone X Applicant’s Signature (required) By signing above I indicate my acceptance of the terms and conditions of the Agreement below. Company Information Company Name CID Program Administrator’s Name Program Administrator’s Telephone Program Administrator’s Mailing Address X Program Administrator’s Signature (required) By signing above I indicate my acceptance of the terms and conditions of the Agreement below. Agreement: Company and the Applicant (a) request that a Corporate Card be issued to the Applicant on the Company’s account, (b) authorize the receipt and exchange of credit information on the Company and the Applicant, (c) agree to be bound by the Agreement sent with the Card and by the Agreements covering Corporate Card related programs in which the Applicant is enrolled, and (d) agree that the Corporate Card will be used for business or commercial purposes only. The Applicant (a) authorizes American Express to notify the Company if this application is declined or if spending restrictions are applied to the Corporate Card, and (b) agrees to be liable for payment to American Express of all amounts charged to the Corporate Card. Do Not Complete - Internal Use Only Reinstatement Decision: Fully Functional / FSF / Decline Limit (if any): Overall $ ___________ All requests will be subject to external credit checks. Both Applicant and Program Administrator will be notified by mail of the decision. BCA# Internal History Retail $ ___________ Early Suspension Code Y / N Applicant Credit Bureau Score Decline Reasons (if any) Decision By: Title/Area American Express Travel Related Services Company, Inc. (Rev. 10/00) Printed in USA