Check Reissue Request Form - Central Connecticut State University
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1CHECK REISSUE REQUEST FORM
Fax or mail to:
Brian P. Vanderoef, Business Office
Central Connecticut State University
1615 Stanley Street
New Britain, CT 06050
FAX# 860-832-2522
Name_______________________________________
Address_____________________________________
_____________________________________
_____________________________________
Student/Vendor ID#____________________________________
Check Amount $___________________ Issue Date:______________
_______
I certify that I have not received the check indicated
above or have received the check and lost it. I request a stop
payment order be placed on this check, and a new check be
issued to me at the above address. I understand that should I
receive/locate the original check, I will return it to the
Business Office at CCSU. Please do not attempt to deposit
original check, as you may be assessed a fee from your bank.
SIGNATURE______________________________ DATE_____________________
PRINT NAME____________________________ PHONE#____________________
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Parent category: Business