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OFFICE OF PROPERTY & MATERIALS MANAGEMENT

UCHC Surplus Property On-Line System

SIGNATURE/ACCOUNT AUTHORIZATION AND MAINTENANCE FORM - PA-20a

Please fill in the following information for the employee who is authorized to sign for your Institution/Organization account(s).

Date:    

State of Connecticut:    Agency          Municipality       School         Non-Profit Organization   

Institution:      

Department:

Mailing Address:          
        
City:       State:              Zip+4:    
                                               

AUTHORIZED EMPLOYEE:            

Telephone:        E-Mail Address: 

TITLE:     

NT USER NAME:  

EMPLOYEE SIGNATURE:     _____________________________________________     

DATE:                           Fax Number: 

AUTHORIZED BY:           

TITLE:   

Telephone:                  E-Mail Address: 

SIGNATURE:  ____________________________________________        

DATE:                           Fax Number: 

REQUEST:                 Add new user and   account(s)     Add following accounts or update expiration dates
                                   Delete user and associated accounts      Delete following accounts

FOR OFFICE USE ONLY:

User ID: _____________________________ Date: ____/____/____

Password: _____________________________        Signature (OPMM):      _____________________________________

AUTHORIZED FOR ACCOUNTS:                 

Ship-To No.                                           
                                      Ledger -  Account                                Expiration Date                         Ship To Location

 

Mail or Fax the completed form to The UCHC Office of Property Administration - Fax 860-679-1993.