Rev 08/12/2010
Grambling State University
AUTHORIZATION FOR "ELECTRONIC DEPOSIT"
New Application for Electronic Deposit
Change of Account Number, same Bank
Change of Bank
I, _____________________, hereby authorize Grambling State University to "Electronically Deposit" my
funds on a date specified by the University to the bank of my choice. (Please circle applicable relationship to
the university.) It is also understood that it is my sole responsibility to notify the University of my bank
account information as well as any changes made to my bank account. In the event of an error in the credit
entry, the correction of which requires that a reversing (debit) entry is made, I hereby authorize the Depository
Institution to initiate such a debit entry in the amount of the error to my account.
Student, Faculty, or Staff Member Signature: _____________________ Date: __ /__/__
If a student, check if form is for _____ Payroll or _____ Student Refunds
If an employee, check if form is for_____ Payroll or ______Reimbursements
Campus-Wide ID Number (CWID): ____________________________
Campus Extension or Other Contact Number: ____________________
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Financial Institution Name: ______________________________
Financial Institution ABA (Routing) Number: ______________________________
Account Number: Checking Savings ______________________________
This section is for GSU employees (faculty/staff) only
Is this a second direct deposit account? Yes No
If yes, specify amount to be deposited to this account per pay period:
________________________________________________________________________________
________________________________________________________________________________
