Print Form
MSU Account Application Form
Reason for request:_______________________________________________________
New Index Name ______________________________________________________
If Name Change: Old Name ______________________________________________
Source of revenue:_______________________________________________________
Contact Person __________________________________ Phone # _____________
Email __________________________________ Dept (Org) # ___________________
Projected Annual Revenues____________ Projected Annual Expenses______________
Dept name ___________________________________________________________
Approvals:
Director of Fund__________________________________ Date ______________
signature
Please call University Business Services (UBS) to discuss application
before completing form x5727
Please read #3 to the left and print name and title
Department Head ________________________________Date ______________
signature
Check all that apply:
New index #
New fund #
New Dept (Org) #
go to 1 below
Please read #3 to the left and print name and title
Change Org on existing index #
Dean/Director ___________________________________Date ______________
signature
New program
Vice President ___________________________________ Date ______________
Yes or No
1. Are the funds received as a gift? If yes, what (if any) restrictions
signature
have been placed on the use of the funds? ____________________________
Vice President for Administration & Finance Use Only
Identify any deliverables required as a condition of the gift. __________________
Budget ______________________________________
Date ______________
signature
Univ Bus Svc __________________________________ Date ______________
signature
Yes or No
2. Will any intellectual property be developed during the course of, or
as a result of, any use of these funds under this account? __________________
Asst VP
__________________________________ Date ______________
for Financial Services
signature
3. By their signatures the Director of Fund and Department Head
For UBS use only
acknowledge their responsibility to ensure that the index maintains
a positive cash balance. One or more backup indexes with adequate resources
Index# ________________
Revenue Account________________
must be identified from which funds may be transferred by the Vice President for
Administration and Finance should the index incur a negative balance. Please
Fund # ________________
Pred Fund_____________Fund Type _______
provide the backup index names, index numbers and department names.
First Backup Index # _________________________________________________
Dept (Org) # ________________
Pred Org______________
Second Backup Index # _______________________________________________
Program # ________________
Effective Date_______________________
Attach detail budget if necessary (not required for a grant, IDC, plant, debt, or auxilliary fund)
Revised NewAcctAppMSUWebForm
Revised 2/17/2012