Finance and Administration
 
Request for New Account
Date of Request 2/4/2012
   
Source of Funding
   
Other Source of Funding Explanation
   
Requested Account Name or Project Title
 
   
Approved Funded Project Period (if externally funded grant)
Start Date
End Date
   
Purpose of Account
(Further explain the source of funds and specify use)
   
Function
   
List of Authorized Signature Approval(s) Below
Name Title
   
Select one of the following options to determine if a combination of more than one signature is required on a transaction or if any one of the authorized signature approvals listed may approve a transaction.
   
Requestor's Name
 
   
Requestor's Email Address
 
   
Enter the code below before submitting your form.
   
Please review the form carefully before submitting.
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Mississippi Institutions of Higher Learning | 3825 Ridgewood Road | Jackson, MS 39211