Common Contracts
1 similar Electronic Funds Transfer (Eft) Authorization Agreement contracts
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • February 2nd, 2017
PROVIDER INFORMATION 1Provider Name: 2Provider Address - Street: 3City: 4State/Province: 5ZIP Code/ Postal Code: PROVIDER IDENTIFIERS INFORMATION 6Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): 7National Provider Identifier (NPI): PROVIDER CONTACT INFORMATION 8Provider Contact Name: 9Telephone Number: ( ) - 10Email Address: FINANCIAL INSTITUTION INFORMATION 11Financial Institution Name: 12Financial Institution Address - Street: 13City: 14State/Province: 15ZIP Code/ Postal Code: 16Financial Institution Telephone Number: ( ) - 17Financial Institution Routing Number: 18Type of Account at Financial Institution: Checking Savings 19Provider’s Account Number with Financial Institution: 20Account Number Linkage to Provider Identifier - Provider Tax Identification Number (TIN) SUBMISSION INFORMATION Reason for Submission (check on
