AUTOMATED CLEARING HOUSE (ACH) ENROLLMENT AND AUTHORIZATION FORM
Check One: New Request Account Change Cancel ACH Direct Deposit
For an ACH payment, CSU Channel Islands requires either 1) the individual's name OR
2) the company's name and
Federal Employer ID number, as they appear on your income tax return. Please complete this form and submit to CSU
Channel Islands.
PLEASE PRINT LEGIBLY
First Name, Last Name or Company Name:
Address or PO Box:
Contact Information:
For receive email notification of payment, please provide email address:
Bank Name: Bank Address:
Bank Routing Number:
Bank Account Number: Select one: Checking Savings
I (we) hereby authorize CSU Channel Islands and the Financial Institution named above, to initiate credit entries to my
(our) account indicated above at the depository Financial Institution named above and to initiate, if necessary, debit
entries and adjustments for any credit entries in error. CSU Channel Islands reserves the right to reverse any duplicate
or erroneous credit entries. I (we) certify that the ACH payment is being made to a domestic financial institution and will
not be transferred in its entirety to a foreign institution as part of a back to back transaction.
If signed by a corporate officer, partner or fiduciary on behalf of a business, organization or corporate entity, I certify
that I have the authority to execute this authorization. This authorization is to remain in full force until CSU Channel
Islands has received written notification from an authorized account holder of its termination in such manner as to
afford CSU Channel Islands and its financial institution reasonable opportunity to act on the notice. It is my (our)
responsibility to provide an updated ACH Enrollment Form to CSU Channel Islands updating any changes to my (our)
Financial Institution, routing number and account number(s).
If any action taken by me (us) results in no acceptance of a direct payment by the designated Financial Institution, I (we)
understand that CSU Channel Islands assumes no responsibility for processing a supplemental payment until the amount
of the no accepted deposit is returned to CSU Channel Islands by the Financial Institution.
Authorized Signature: Date:
Printed Name of Authorized Official: Title:
**PLEASE ATTACH A VOIDED CHECK OR OTHER FINANCIAL INSTITUTION DOCUMENTATION WITH CORRECT ACCOUNT
AND ROUNTING NUMBERS HERE TO CONFIRM ACCOUNT INFORMATION** (DEPOSIT SLIPS NOT ACCEPTED)
Submit completed form via email: purchasing@csuci.edu
FAX: (805) 437-8436
For questions, please contact Karina Cruz at: (805) 437-8581
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