East Tennessee State University
Accounts Payable
Direct Deposit Authorization Form
NAME: _________________________________________
Banner ID# or Federal ID#: _________________________________________
DATE: _________________________________________
Notification Email for Direct Deposit :
______________________________________________
*REQUIRED FOR ALL VENDORS
TAPE VOIDED CHECK HERE OR HAVE BANK REPRESENTATIVE COMPLETE BELOW
Financial Institution Information
Name of Bank: _________________________________________________________
Account Type: Checking Savings
Bank Routing Number: ______________________________
Account Number ______________________________
_______________________________________________________________________________
Authorization for Direct Deposit of Accounts Payable Payments
**I hereby authorize East Tennessee State University to direct payments to the financial institution
designated above via electronic funds transfer and to my financial institution to credit this amount
to my account.
**In the event that the exercise of this authorization for any reason results in an overpayment for
vendor invoices actually due and payable to me, I hereby authorize the University to either: A)
debit my above-identified bank account for an amount not to exceed said overpayment, or B)
withhold a sum equal to the overpayment from my next disbursement of vendor invoice payment.
**I understand it is my responsibility to provide the ETSU Accounts Payable office with any changes
regarding my bank account and a copy of a voided check.
**I understand that this authorization applies only to my Accounts Payable record information.
**I also understand that this authorization may be terminated at any time by the University, or named
bank.
Signature: ____________________________________ Date: ____________________
MAIL COMPLETED FORM TO:
ETSU, PROCUREMENT AND CONTRACT SERVICES, PO BOX 70729, JOHNSON CITY, TN 37614
OR FAX TO 423-439-5746
Version 3-8-10
