Russellville Agency Account Approval Form
ACCOUNT # ___________________________________________ YEAR _________
TERM: (Check all that apply): Summer II Fall Spring Summer I
Name of Organization: _____________________________________________________
Name(s) of authorized person(s) to request checks:
1)
___________________________________ _________________________________
_______________
Print Name-Student
Signature
2)
___________________________________ ________________________________ ________________
Print Name-Student Signature
3)
___________________________________ ________________________________ ________________
Print Name-Student Signature
Advisor: _________________________________ _____________________________
Print Name Signature
Advisor Telephone Number: (_______) ___________ - __________
E-Mail Address: ________________________ _______________________________
Campus Building & Room #
Immediate Supervisor of Advisor______________________ _____________________
Print Name Signature
For Office of Student Services Use
Only
I, _____________________________________________, certify that the above name(s)
are authorized to request funds for the named organization during the term indicated.
Approval Desginated by V/P of Student Services: _______________________________
Date: _______________________________
T Number
T Number
T Number
_______________
T #
