Acknowledgement And Power Of Attorney Form printable pdf download

Acknowledgement And Power Of Attorney Form

Acknowledgement and Power of Attorney Form

Citibank Individual Travel Account Program

Acknowledgement

I, _______________________, acknowledge receipt of a Citibank Individual Travel

Account from the State University of New York at Stony Brook (“Stony Brook

University”). As Account Holder, I accept personal responsibility for charges made on

this account in compliance with the applicable policies and regulations of the New York

State Comptroller and Stony Brook University. I agree that I will use this account only

for the purpose of charging airfare/train travel to the State Contracted Travel Agency,

Euro Lloyd, while conducting official University business.

I further acknowledge that, should I incur personal charges and do not repay this

amount, I agree that Stony Brook University shall be entitled to take action under the

Power of Attorney issued herein, to deduct amounts due and owing from checks

payable to me by the State of New York.

Power of Attorney

I, _______________________, residing at

_____________________________________________________________________

with a Stony Brook Solar ID of_______________________, do hereby appoint the

State University of New York at Stony Brook as my Attorney-in-Fact, to act in my name,

place and stead, in any way which I myself could do, to endorse and negotiate any

check or checks which I may receive from the State of New York, for the purpose of

applying such check or checks to any outstanding (undisputed) obligations owed to the

Individual Travel Account , to the extent that such obligations have been assumed and

paid by Stony Brook University.

I have signed my name this___ day of ______, 20__

Signature of Employee ____________________________________

Return form to Porshia Russell, Procurement Z-6000

Acknowledgement And Power Of Attorney Form