University ACH Payment Authorization Form
Complete this form to authorize ACH payment processing for university-related transactions. Please ensure all information is accurate and complete.
Full Name
*
First Name
Last Name
University Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
University Affiliation
*
Please Select
Student
Faculty
Staff
Alumni
Other
University ID or Reference Number
*
Department or Payment Purpose
*
Please Select
Tuition
Housing
Student Fees
Library Fines
Other
Amount to be Authorized (USD)
*
Preferred Payment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Notes or Instructions
Submit
Should be Empty: