Electronic Transfer of Funds Authorization Form

Complete and submit this form to request electronic fund transfers to your institution or company from the Board of Regents, Fiscal Affairs, Accounts Payable Department. [ contact information ]
See the security notice below for information regarding the methods used to transmit data submitted with this form.

NOTE: ALL form fields are required except Secondary Contact information.

Date: October 19, 2017

By submitting this form, you agree to the following statement:
I authorize the Board of Regents and the Financial Institution listed to deposit my (or my company/corporation's) net payment automatically to my (or my company/corporation's) account each time a payment is due me (or my company/corporation). This authority will remain in effect until I (or my company/corporation) cancels in writing.

Contact Information
Board of Regents of the University System of Georgia
Attn: Simone D. Mayweather
Accounts Payable Department
270 Washington Street, S.W.
Atlanta, GA   30334
Tel.: 404-962-3228
Fax: 404-962-3215
Email: Simone.Mayweather@usg.edu

Security Notice: To provide a secure transmission of data, Information Technology Services (ITS) at the Board of Regents system office employs Secure Sockets Layer technology (SSL). SSL, which is supported by a vast majority of Internet browsers available today, is the most commonly employed method of secure, encrypted communication used on the Internet. All data collected is stored on site. The information is only accessible to authorized employees at the University System Office.

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