Southeastern Louisiana University
VENDOR SETUP FORM
Complete and FAX to (985) 549-3802 Questions? Call (985) 549-2068 or send an email to acctspayable@selu.edu
Type of Request Tax Id Legal Name Entity Type Banking Information
New Request Change – Select type(s) of change Remit Address Order Address Contact Information
Taxpayer Identification Number (TIN) (Provide ONE only)
Entity Name-Must provide Legal Name (*Must match SSN or FEIN given. If Individual or Sole Proprietorship enter First, Middle, Last Name)
Remit To Address and Contact
Street Address or PO Box:
City:
State:
Zip Code:
Country:
Title:
Region/Province:
Contact Name:
Phone:
Fax:
E-Mail:
Check here if outside the United States
Country:
State:
Zip Code:
Financial Institution Information (Direct Deposit Payment)
Bank Name:
Bank Address:
City:
Nine Digit Routing Number:
Bank Account Number:
Checking Savings
State: Zip Code:
Country:
Title:
Order information, if different
Street Address or PO Box:
City:
Region/Province:
Contact Name:
Phone: Fax: E-Mail:
I hereby authorize and request Southeastern Louisiana University to initiate credit entries and if necessary, a debit entry in accordance with
National Automated Clearing House Association (NACHA) rules reversing a credit entry made in error, to my account at the financial
institution named. The electronic payment is to remain into effect until withdrawn by written notification to the University.
Yes No – Will the payments you receive from Southeastern Louisiana University be deposited/transferred to an account outside of
the United States? (Yes means receipts are transferred outside the U.S. No means receipts are not transferred outside the U.S.)
Signature below signifies the acceptance of the above terms and conditions:
Signature
Job Title Date
To be complete by Accounts Payable personnel:
Vendor# _________________ Date: _________ Entered by: _______________
Are you a Foreign Individual/Organization (Non-US Citizen)? Yes No
Are you a current or retired member of Teacher's Retirement System of LA (TRSL)? Yes No
Supplemental Information
Social Security Number (SSN)
Legal Name:
DBA:
(if applicable)
Employer Identification Number (EIN)
Individual Taxpayer Identification Number (ITIN)
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click to sign
signature
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