Vendor Electronic Transfer (EFT) Form

Vendor Electronic Transfer (EFT) Form
EFT Form
Select one:*

EnrollmentModification
Vendor Name*
Address*
City*
State*
Zip Code*
Contact Person*
Title*
Fax Number
Contact Email*
example@example.com
Phone Number:*
Email for REMITTANCE NOTIFICATION*
example@example.com
Financial Institution Information

A VOIDED CHECK OR DIRECT DEPOSIT FORM MUST ACCOMPANY THIS FORM
Financial Institution Name*
ABA Routing*
Account Number*
Address*
City*
State*
Zip Code*
Voided check or direct deposit form:*

Cancelof
I authorize the City of Melissa to deposit funds via EFT to the account indicated above for the purpose of paying vendor invoices.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: