AP DIRECT DEPOSIT AUTHORIZATION

Please complete, sign and return this form to Accounts Payable E-MAIL…………………………………………… [email protected] FAX……………………………………………………………………. 619-849-7049 **INCOMPLETE OR ILLEGIBLE FORMS WILL BE RETURNED TO PAYEE**

Vendor Information Change

New

Check One:

Discontinue ACH

Payee Name:

Payee ID: (Last Name, First Name, MI)

By signing below, I authorize PLNU to process payment for all invoices via ACH direct deposit. I understand that I am responsible to contact PLNU Accounts Payable (email or fax above) with updates in the event my/our banking information changes. This agreement is to remain in effect until PLNU has received written notification from me to terminate this agreement.

Print Name & Sign:

Date:

Please Email Remit Information to:

Phone:

Financial Institution Name of Bank: Routing #: Account Type:

Account #: Checking

Savings

Please attach a voided check here

Below for Accounts Payable Use Only CARs Entry Date:

Entered By:

Deposit Form 2/2012