Request for Vendor EFT Information

Vendor Information

Vendor Name: ______________________________________________

Remittance Address: ______________________________________________

Remittance City: _______________ State: _________ Zip Code: ________

Contact Name: ____________________ Phone#: ____________________

E-Mail Address: ________________________________________________

Banking Information

Vendor’s Bank Name: _______________________________________________

Bank Address: _______________________________________________

Bank’s City: _________________ State: ________ Zip Code: _______

Bank Contact Name: ___________________ Phone#: _____________________

ABA Routing#: ___________________ Account#: ____________________

Account Type: Checking ______ Savings ______

Completed Form__________________ Copy of Voided Check__________________

W-9___________ Certificate of Liability for 2019 (if applies) ____________________

Vendor Authorization:

Signature: _____________________ Title: _____________________ Date:_________

Thank you!