DEFINITY ACH Form

ACH FORM
AUTOMATED CLEARING HOUSE (ACH) AUTHORIZATION AGREEMENT
1. Please e-mail form to [email protected] or FAX to (877) 289-4778
2. ALL information is REQUIRED. Incomplete form will delay processing.
Part I: Reason for Submission
REVISION to Bank Account information
NEW ACH Authorization
Since your last ACH Authorization Agreement submission, have you had a:
CHANGE of Location
CHANGE of Ownership, and/or
If you checked either a change of ownership or change of location above, please contact your Essilor business contact to get
your information officially changed. Do not submit this form until Payee is notified by Essilor that the update is completed.
Part II: Payee Information
LEGAL BUSINESS NAME
STREET ADDRESS / REMITTANCE LOCATION
CITY
STATE
ZIP CODE
PAYEE CONTACT NAME
TELEPHONE
FAX
IRS TAX IDENTIFICATION NUMBER (EIN or SSN)
PAYEE REMITTANCE EMAIL ADDRESS (provide only one)
Part III: Financial Institution Information
A separate ACH form is required for EACH location/bank account.
IMPORTANT: Required Financial Institution documents are either a Voided Check or a Bank Letter confirming the account information.
The document should contain: the payee name as it appears on the bank account, electronic routing transit number and bank account
number for verification. Processing of the ACH payment will be delayed without this information.
Part IV: Authorization
By signing below, I hereby authorize Essilor to initiate credit entries and initiate adjustments for any duplicate or erroneous entries made to
the financial institution/bank account indicated. I further authorize the financial institution/bank named to credit and/or debit the same to
such account.
If payment is being made to an account controlled by a corporate office, the payee hereby acknowledges that payment to the Corporate
Office under these circumstances is still considered payment to the Payee, and the Payee authorizes the forwarding of Essilor payments to
the Corporate office.
This Authorization Agreement is effective as of the signature date below and is to remain in full force and effect until Essilor has received
written notification from Payee of its termination in such time and such manner as to afford Essilor and the Financial Institution a reasonable
opportunity to act on it. Essilor will continue to send the direct deposit to the Financial Institution indicated until notified by Payee that Payee
wishes to change the Financial Institution receiving the direct deposit. If Financial Institution information changes, Payee agrees to submit to
Essilor an updated ACH Authorization Agreement.
Signature
AUTHORIZED/DELEGATED OFFICIAL NAME (PRINT)
AUTHORIZED/DELEGATED OFFICIAL TITLE
AUTHORIZED/DELEGATED OFFICIAL SIGNATURE ( Note: Must be original signature in black or blue ink )
Date
©2013 Essilor of America, Inc. All rights reserved. Unless indicated otherwise, all trademarks are the property of EssilorInternational and/or its subsidiaries in the United States and in other countries.
LDEF200292 PDF/ECST 6/13
1 of 2
ACH Appendix
Required Financial Institution documents are either a Voided Check or a Bank Letter confirming the account information. The document
should contain: the payee name as it appears on the bank account, electronic routing transit number and bank account number for
verification. Processing of the ACH payment will be delayed without this information.
Please attach a Voided Check here
102
My Name
My Address
City, State, ZIP
Pay to the
order of
$
Dollars
Bank Name
Bank address
471659165
225466946413
102
©2013 Essilor of America, Inc. All rights reserved. Unless indicated otherwise, all trademarks are the property of EssilorInternational and/or its subsidiaries in the United States and in other countries.
LDEF200292 PDF/ECST 6/13
2 of 2