Common Contracts
2 similar Authorization Agreement for Electronic Funds Transfer (Eft) contracts
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • December 7th, 2020
VENDOR INFORMATION 1. VENDOR LEGAL BUSINESS NAME (must match name on financial institution account and name registered with Alliance Health, if applicable) 2. ACCOUNT HOLDER’S NAME 3. CONTACT TELEPHONE NUMBER 4. VENDOR ADDRESS CITY STATE ZIP 5. VENDOR COMPLETE FEDERAL TAX ID NUMBER (must match number registered with Alliance Health, if applicable) 6. EMAIL ADDRESS – for Electronic Remittance Forms to be Sent
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • August 7th, 2013
This authorization is effective as of the signature date below and is to remain in full force and effect until Alliance Health has received written notification of its termination in such time and such manner as to afford Alliance Health and the financial institution a reasonable opportunity to act on it, or until Alliance Health deems it necessary to terminate this agreement. Under penalties of perjury, I hereby certify the checking OR savings account indicated on this form are under my direct control and access; therefore, I authorize Alliance Health to initiate, change, or cancel credit entries to the financial institution account as indicated above. If my financial institution information changes, I agree to submit to Alliance Health a revised Authorization Agreement for Electronic Funds Transfer form.
