ORU Payment Enrollment Form
See page 2 for Terms and Conditions
Oral Roberts University
7777 S Lewis Ave, Tulsa, OK 74171
918-495-7531/7549
fax: 918-495-6985
Block 1 - INDIVIDUAL OR COMPANY INFORMATION
SSN# __ __ __ - __ __ - __ __ __ __ FEIN# __ __ - __ __ __ __ __ __ __
Name: _________________________________ Name: __________________________________
Address: ________________________________ Address: _________________________________
Physical Street Address (required) Physical Street Address (required)
Address: ________________________________ Address: _________________________________
Mailing Address Mailing Address
_______________________________________ ________________________________________
City, State and Zip Code
City, State and Zip Code
Phone ( __ __ __ ) __ __ __ - __ __ __ __ Phone ( __ __ __ ) __ __ __ - __ __ __ __
Block 2 - FINANCIAL BANK INSTITUTION INFORMATION
Bank Institution Name: _____________________________________________
Institution Account Number: ________________________________________
Nine-Digit Routing Number: __ __ __ __ __ __ __ __ __
Please Check Type of Account: ___ Checking ___ Savings
Block 3 - NOTIFICATION METHOD
Notification of your deposit confirmation will be sent via e-mail.
Email Address (required): _________________________________________________
Signature: ___________________________________________ Date: __________________
Printed Name: _______________________________________ Title : __________________
If you have any questions concerning ACH Transactions, please contact Mary Ellen Crosby or Reba Johnson
918-495-7531/7549 or Fax 918-495-6985.
___ Updated in Banner Processed By: ________________________________ Date: _____________
By signing below, I acknowledge that I have read, understand and agree to the Terms and Conditions on Page 2 and that I have
the authority to execute this authorization on behalf of the vendor. This authorization is to remain in full force until Oral Roberts
University has received written notification from me of termination in such time as to afford a reasonable opportunity to act on it.