Common Contracts
2 similar Electronic Funds Transfer (Eft) Authorization Agreement contracts
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • September 13th, 2017
Provider Information (required) Provider Name Street Address City State ZIP Provider Identifiers Information (required) Provider Federal Tax Identification Number(TIN) or Employer Identification Number (EIN) National Provider Identifier (NPI) Provider Contact Information (required) Provider Contact Name Telephone Number Telephone Number Extension Email Address Authorization Agreement for Automatic Deposits (Automated Clearing House Credits)I, provider name (“PROVIDER”), hereby authorize eClusive, LLC (“COMPANY”) to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to PROVIDER’s checking/savings account(s) indicated below and the bank named below (“BANK”), to credit and/or debit the same account. Financial Institution Information (required) Please provide PROVIDER’s bank account information below. Financial Institution Name Street Address City State ZIP Financial Institution Routing Number Type of Account at Financial Institution C
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • September 13th, 2017
Provider Information (required) Provider Name Street Address City State ZIP Provider Identifiers Information (required) Provider Federal Tax Identification Number(TIN) or Employer Identification Number (EIN) National Provider Identifier (NPI) Provider Contact Information (required) Provider Contact Name Telephone Number Telephone Number Extension Email Address Authorization Agreement for Automatic Deposits (Automated Clearing House Credits)I, provider name (“PROVIDER”), hereby authorize eClusive, LLC (“COMPANY”) to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to PROVIDER’s checking/savings account(s) indicated below and the bank named below (“BANK”), to credit and/or debit the same account. Financial Institution Information (required) Please provide PROVIDER’s bank account information below. Financial Institution Name Street Address City State ZIP Financial Institution Routing Number Type of Account at Financial Institution C
