Please print this page and complete the required information.  Upon completion, mail form and voided check to:
   UT Martin Development Office
   328 Administration Building
   Martin, TN 38238

AUTHORIZATION AGREEMENT FOR

PRE-AUTHORIZED PAYMENTS

THE UNIVERSITY OF TENNESSEE AT MARTIN
UT FOUNDATION

I (we) hereby authorize UT Martin to initiate debit entries to my (our) checking account indicated below. The depository financial institution named below will receive and debit the same entries to my (our) account.

BANK NAME_______________________            ADDRESS _________________________

CITY_______________________________            ST_____________ ZIP ______________

ROUTING NUMBER __________________            ACCOUNT # ________________

DOLLAR AMOUNT PER MONTH $_______________

This authority is to remain in full force and effect until I (we) notify UT Martin and the financial institution of its termination.

NAME(S)____________________________ SS# ______________________________

DATE_________________

SIGNED______________________________________

SIGNED______________________________________

Please provide a voided check to verify account information.