Student Organization Agency Account Authorization 1. Student Organization's Name: _____________________________________ 2. Initial Deposit Amount: $ _______________________ 3. Purpose of the Funds: ___________________________________________ ______________________________________________________________ 4. Sources of Income: ______________________________________________ 5. Persons to manage the account: Student's Name ________________________________________________ Position _______________________________________________________ Address ______________________________________________________ Phone Number(s) _______________________________________________ Advisor's Name _________________________________________________ Title __________________________________________________________ Department ____________________________________________________ Phone Number(s) _______________________ Box # __________________ 6. How are funds to be disposed if the organization is dissolved? * ______________________________________________________________ 7. Acceptance: _______________________________________________ ________________ Originator Date _______________________________________________ ________________ Director of the Student Center & Leadership Activities Date _______________________________________________ ________________ Dean of Campus Life Date * IF NO TRANSACTION OCCURES FOR A ONE YEAR PERIOD AND NO PROVISION IS MADE FOR DISPOSAL OF FUNDS, THE FUNDS WILL BE TRANSFERRED TO THE S.G.A. AGENCY ACCOUNT TO BE DISPURSED TO STUDENT ORGANIZATIONS. ============================================================= For Comptroller Office Use Agency Account Number Assigned: ___________________________________ Date __________________________