ACH VENDOR PAYMENT AUTHORIZATION FORM



ACH VENDOR PAYMENT AUTHORIZATION FORMThis form is used for Automated Clearing House (ACH) payments. The information being collected on this form will be used to transmit payment data, by electronic means, to your financial institution. Failure to provide the requested information may delay or prevent the receipt of payment through ACH Payment System. Recipients of the payments should bring this information to the attention of their financial institution when presenting this form for completion. Recipients should also request to be notified immediately regarding any change occurring at the financial institution that may delay or prevent the receipt of scheduled payments.72390059690VENDOR INFORMATIONNAME :____________________________________________________________ADDRESS :_________________________________________________________CONTACT NAME :__________________________________________________CONTACT EMAIL & PHONE:________________________________________FEDERAL I.D.#:_______________________________________________________________________________________________________AUTHORIZED SIGNATURE00VENDOR INFORMATIONNAME :____________________________________________________________ADDRESS :_________________________________________________________CONTACT NAME :__________________________________________________CONTACT EMAIL & PHONE:________________________________________FEDERAL I.D.#:_______________________________________________________________________________________________________AUTHORIZED SIGNATURE723331-199FINANCIAL INSTITUTION INFORMATIONBANK NAME:__________________________________________________________________BANK ADDRESS:_______________________________________________________________(9) DIGIT ROUTING NUMBER:___________________________________________________DEPOSITOR ACCOUNT NAME:__________________________________________________DEPOSITOR ACCOUNT NUMBER:_______________________________________________TYPE OF ACCOUNT: □ CHECKING □ SAVINGS__________________________________________________ (______)_______________SIGNATURE & TITLE OF BANK REPRESENTATIVE PHONE NUMBER00FINANCIAL INSTITUTION INFORMATIONBANK NAME:__________________________________________________________________BANK ADDRESS:_______________________________________________________________(9) DIGIT ROUTING NUMBER:___________________________________________________DEPOSITOR ACCOUNT NAME:__________________________________________________DEPOSITOR ACCOUNT NUMBER:_______________________________________________TYPE OF ACCOUNT: □ CHECKING □ SAVINGS__________________________________________________ (______)_______________SIGNATURE & TITLE OF BANK REPRESENTATIVE PHONE NUMBER ................
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