FINANCE DEPARTMENT QUESTIONNAIRE:

Authorization

I hereby authorize Winrock International to initiate automatic working funds deposits to my

account from the Finance Department named below. Further, I agree not to hold Winrock
International for any delay or loss of funds due to incorrect or incomplete information supplied
by me or by my financial institution or due to an error on the part of my financial institution in
depositing funds to my account.

This agreement will remain in effect until Winrock International receives a written notice of
cancellation from me or my financial institution, or until I submit a new direct deposit form to
the Finance Department.

Account Information

Name of Financial Institution :

Routing Number :

Account Number : ☐ Checking | Savings ☐

What is your preferred method of payment :

Online Access : ☐ Yes | No ☐

How long have you been using their services :

How would you rate their services (1-10) :

What is your card type ( credit or debit ) :