Roosevelt University Direct Deposit (ACH)
Service Provider/Vendor Application Form
On behalf of (entity named below) I have the authority to and hereby authorize Roosevelt University to make payment of written claims submitted to
Roosevelt University by electronic deposit to the account listed below until this authorization is revoked in writing and upon reasonable notice to Roosevelt
University. By signing this document, I certify that the bank account information provided is correct. I further authorize Roosevelt University to
electronically and without notice deduct from this account any funds mistakenly deposited therein by Roosevelt University.
I hereby declare that written claims submitted to Roosevelt University are and will continue to be just and correct and that no written claim shall be submitted
where such claim has already been paid. If any written claim submitted to Roosevelt University has resulted in a duplicate payment, I hereby authorize
Roosevelt University to electronically deduct from this account any funds paid on a claim that has already been paid.
Vendor Number (for office use only) _________________________
Company or Individual Legal Name __________________________________________________________________________
Tax I.D. # (EIN) or Social Security Number _____________
Address __________________________________________________________________________________________________________
City ________________________________________________________________ State __________ Zip Code _________________
Contact Person __________________________________________________________ Phone # ______________________________
Email Address (for ACH notification & Remittance Advice) ___________________________________________
Bank Information:
Name of Bank ______________________________________________________________
Routing Transit Number (9 characters)
Account Number
(Please check one) Checking Account ________ Savings Account ________
Account Holder’s Signature __ _______________ _________________________ Date ________________________
Title (if applicable) _____ __________________________________________
Return To:
Email is the preferred method of delivery
accountspayable@roosevelt.edu
Questions?
Call Darlene Morris-Fullerton at
(312) 341-3561 or fax form to (312) 341-3595
click to sign
signature
click to edit
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