CTAC Fiscal Account Form

Account User Information Section

User Name*

First Last

Email*

Phone*

Bill to (PI name)*

First Last

Address*

Department Building Room #

Phone*

FAX*

Email*

Fiscal Information Section

Fiscal Contact Name*

First Last

Phone*

FAX*

Email*

Some lines below may be blank. Please use a hyphen / minus sign ("-") for blank entries. Your Fiscal Administrator will know which fields are necessary for the funding source that you are using.

Chartfield Info: Department I.D.*

Chartfield Data

Chartfield Info: Fund*

Chartfield Data

Chartfield Info: Program*

Chartfield Data

Chartfield Info: Account*

Chartfield Data

Chartfield Info: Source*

Chartfield Data

Chartfield Info: Budget Reference*

Chartfield Data

Chartfield Info: Flex*

Chartfield Data

Chartfield Info: Project*

Chartfield Data

PI Grant Reference*

Descriptive name for the PI to identify the funding source. (ie: NIH RO1, Start-up, Am Heart Assn., etc.)

The Principal Investigator signature below gives MBI - CTAC authorization to charge the above chartfield for goods and services rendered to the user listed above.

P.I. Signature*

Date*

University of Florida

Cell & Tissue Analysis Core

University of Florida, McKnight Brain Institute

CTAC Fiscal Account Form

Account User Information Section

Fiscal Information Section