Government Treasury Account Certifying Officer Authorization Form

Government Treasury Account Certifying Officer Authorization Form
Complete this form to authorize a certifying officer for your government treasury account. Please ensure all information is accurate and complete.
Officer's Full Name
First NameLast Name
Officer's Job Title
Department or Agency Name
Work Email Address
example@example.com
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Office Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Supervisor/Authorizing Official's Full Name
First NameLast Name
Supervisor/Authorizing Official's Work Email
example@example.com
Effective Date of Authorization
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: