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VENDOR ACH PAYMENT AUTHORIZATION AGREEMENTPayment Authorization Agreement • June 22nd, 2017
Please Check One: New ACH Payment Change ACH Payment Cancel ACH Payment Initiate ACH Payment From: (check all that apply) Pine State Trading (Corporate) Pine State Beverage Pine State SpiritsNew vendor accounts must include IRS form W9 with submission of application (form attached) Vendor Information: Vendor Name: Tax ID #: Street: City/State/Zip: Contact: Telephone #: Remittance Email Address: Bank Information: Bank Name: Bank Account #: Bank Routing/Transit #: Checking - attach copy of voided check (REQUIRED) SavingsIn lieu of a check copy, a bank certified letter with your bank account information may be accepted. Approvals/Authorizations: I certify that the information provided on this form is correct, and I hereby authorize Pine State Trading and/or it's divisions as specified above (Pine State Beverage and Pine State Spirits, Agents of the State of Maine) to initiate debit and/or credit entries to the account and bank indicated above. I understand that this authorization wi
