Vendor ACH Payment Enrollment Form
Note: Checks are negotiable for only 90 days (reduced from 180 days.)
Please check one of the following:
New
Change
Payee / Company Information
Name:
Current Mailing Address:
Social Security or Taxpayer ID (Required):
Contact Person Name:
Home Telephone:
Mobile Telephone:
Work Telephone:
Email Address:
Financial Institution Information
Name:
Address:
Nine-digit Routing Transit Number (usually first set of nine-digit numbers at bottom of check):
Account Number:
Type of Account:
Checking
Savings
Name of Payee or Authorized Official (please print):
Signature and Title of Payee or Authorized Official (required):
Date: