Please print out out this page, fill in the form, and return it to:

Office of Development & Alumni Relations
Carlin Alumni House
Central Michigan University
Mount Pleasant, Mich. 48859
Phone: (800) 358-6903 or (989) 774-3312
Fax: (989) 774-7159
E-mail: alumni@cmich.edu

For more information, please contact us at the address above or read our Centralink web page.

I hereby authorize Central Michigan University to make withdrawals on the 10th of each month (or the first business day thereafter) from the account identified below at _________________________ (Depository Financial Institution, hereinafter referred to as DFI) and authorize the DFI to charge such withdrawals to my listed account.

Such payments will be in the amount of $ ___________ .
If the purpose for withdrawal is restricted in any manner, such restriction is stated below. Adjusting entries to correct errors are also authorized. It is agreed that these withdrawals and adjustments may be made electronically and under the rules of the Michigan Automated Clearing House Association. This authorization will remain in effect until written notice of termination is given to the university. I acknowledge receipt of a filled-in copy of this authorization.

Name of DFI: ________________________________________

DFI's Routing & Transit No. |__|__|__|__|__|__|__|__|__|

Account No. to Debit |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Type of Account: Checking: ______ Savings: ______

Name of Authorizing Party (Please print):

 _____________________________________

Address: ______________________________

City: _________________________________

State: ________________________________

Zip Code: _____________________________

Signature of Authorizing Party:

 X_______________________________

Date: __________________________