2/7/2017
Vendor Direct Deposit Agreement Form
Authorization Agreement
I hereby request and authorize Clarke University to deposit payments to the account provided below. In situations where a
payment has been made in error, Clarke University is authorized to correct that error. This agreement will remain in effect
until Clarke University receives a written notice of change or cancellation from me or my financial institution, or until I
submit a new direct deposit form to the Accounts Payable Office.
Vendor Information
Type of Authorization
New
Change
Cancellation
Business Name
Tax ID#
Street Address
City
State
Zip
Email address for
notification of payment*
*An email is required in order to receive notification of payment to your account.
Account Information
Name of Financial Institution
Routing Number (9 digits)
Account Number
Checking
Savings
Signature
Authorized Signature (Primary)
Date
Authorized Signature (Joint)
Date
Please return this form to: Clarke University, Attn: Accounts Payable, 1550 Clarke Drive, Dubuque, IA 52001
or by fax to 563-588-6789
or email to accountspayable@clarke.edu
For Accounts Payable Office Use Only
Vendor #
Date Received
Date Input
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