ࡱ> .0-Y  bjbj h h 2kbkb `````tttt t.www(******$N`wwN``c ``((`}u Zy0'''`hw>,$wwwNN~.www'wwwwwwwwwB &: 91Ʒ CONTROLLERS OFFICE STAFF AGENCY ACCOUNT FORM REQUESTED BY: ________________________________ (Print or type name) (Signature) TYPE OF REQUEST (check one): ____ New Account ____ Renewal of Account ____ Change of Signature(s) NAME OF ACCOUNT ________________________________________________ PURPOSE OF ACCOUNT___________________________________________________ SOURCE OF FUNDS _____________________________________________ AUTHORIZED SIGNATURES: ____________________________________ _____________________________________ print name print name ____________________________________ _____________________________________ signature signature Office Address and Telephone: Office Address and Telephone: ____________________________________ _____________________________________ ____________________________________ _____________________________________ TERMINATION INFORMATION: Use of this account will terminate on June 30th of the fiscal year at which time it may be renewed by filing a new Agency Account Form with the Controllers Office. If the account is not renewed, funds will be given to the Department Sponsor. DEPARTMENTAL SPONSOR: All Agency Accounts must have a department sponsor. The departmental sponsor is responsible for any deficit in the Agency Account. Account Number: ____________________________________________________ Signature of Department Head: ______________________________________________ APPROVALS: Dean or Vice President: ______________________________________________ Controllers Office: _________________________________ Account Number: ___________________________ DATE: ____________________ PLEASE SUBMIT TO THE CONTROLLERS OFFICE ONCE COMPLETED. HIJ|  " # r  ؿ؞ؔ}hyhy5OJQJhyhyOJQJhyCJOJQJh/~5CJOJQJ\hi}CJOJQJhCJOJQJhphpCJH*OJQJh/~>*CJOJQJh/~CJOJQJh/~OJQJh/~>*OJQJh/~5OJQJh/~/IJKL> ? @   ! m `@&$a$$@&a$@& * , w x r s  `a@& $a$gdy0P&P/ =!"#$% s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH 8`8 Normal_HmH sH tH PP  Heading 1$<@&5CJKHOJQJDA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 8>@8 Title$a$ 5OJQJ@Y@  Document Map-D OJQJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<     8@0(  B S  ?ݝݝݝݝ " "=*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName9*urn:schemas-microsoft-com:office:smarttagsplace "/5JL=>@@ #ss" #"% yK,5?Gp2vi}/~/w Ef*60d(U' "@ @UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaA$BCambria Math"hܢLGܢLGjv  242HP??G0!xx CLEVELAND STATE UNIVERSITYKathy StoessnerHolly A ElliottOh+'0 $ D P \ ht|91ƷKathy Stoessner Normal.dotmHolly A Elliott2Microsoft Office Word@F#@5t1@]Z@]Z՜.+,0 hp  91Ʒ  91Ʒ Title  !"#$&'()*+,/Root Entry F@d Z11Table 'WordDocument2SummaryInformation(DocumentSummaryInformation8%CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q