Vendor #
Approved
PreNote
AP Use Only
CHECK ONE: New Request
Change of Bank or Account Number
Delete Authorization
Employee/Student Name
Bank Name:
Bank Address:
Checking
Savings Bank Account Number:
****IMPORTANT ***** Please attach a voided check OR confirm your routing and bank account number with your
Bank Routing Number:
EMPLOYEE / STUDENT Direct Deposit
Reimbursement/Payment Authorization
Form
banking institution. Your Debit Card number is NOT your bank account number.
Email address(es) to send payment notification (please print):
Signature: Date:
Telephone Number: E-Mail:
Allow two weeks for processing.
Printed Name
Forward original form to CMA Accounting Manager
Signature
I hereby authorize in accordance with the rules and regulations of the National Automated Clearinghouse
Association ("NACHA") California State University ("CSU"), The California Maritime Academy to credit any
reimbursements due to the entity listed above as "Vendor Name" via automated clearinghouse electronic fund
transfer ("ACH") to the bank and bank account owned by the vendor referenced above. Further, I hereby authorize
CSU to withdraw funds from the above referenced bank account owned by the vendor via ACH debit. Such debits
are authorized only to perform legitimate and appropriate financial transactions between above vendor and the CSU
including, but not limited to, retrieval of reimbursement overpayments. This authorization will remain in effect until
cancelled in writing. A new authorization must be completed if there is a change to the bank account, the bank
account is closed, or there is a change in financial institutions.
Note: I understand that the California State University (CSU) requires ten (10) business days to set up this initial
authorization and two (2) business days for funds to become available following an ACH electronic funds transfer.
Privacy Notification
The State of California Information Practices of 1977 (effective July 1, 1978) requires the University to provide the following information to
individuals who are asked to supply information about themselves. The principal purpose for requesting information on this form is to acquire
authorization for reimbursement distribution to a financial institution of the individual's choosing. Furnishing all information on this form is
mandatory. Failure to provide such information will delay or may even prevent completion of the action for which the form is being submitted.
Submitted document is scanned & filed in limited access file; originals are destroyed.
click to sign
signature
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