Southeastern Louisiana University VENDOR SETUP FORM Remit

Southeastern Louisiana University
VENDOR SETUP FORM
Complete and FAX to (985) 549-3802 Questions? Call (985) 549-2068 or send an email to [email protected]
Type of Request
 New Request
 Tax Id
 Change – Select type(s) of change
 Legal Name  Entity Type  Banking Information
 Remit Address
 Order Address
 Contact Information
Taxpayer Identification Number (TIN) (Provide ONE only)
Social Security Number (SSN)
-
-
or Federal Employer Identification Number (FEIN)
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Entity Name-Must provide Legal Name (*Must match SSN or FEIN given. If Individual or Sole Proprietorship enter First, Middle, Last Name)
Legal Name*
Remit To Address and Contact
Name To Make Payment To, if different than above:
Street Address or PO Box:
City:
State:
Region/Province:
Country:
Zip Code:
Contact Name:
Title:
Phone:
Fax:
E-Mail:
Financial Institution Information (Direct Deposit Payment)
 Check here if outside the United States
Bank Name:
Bank Address:
____________________________________
Country:
City:
State:
Nine Digit Routing Number:
Zip Code:
 Checking  Savings
Bank Account Number:
Order information, if different:
Street Address or PO Box:
City:
State:
Region/Province:
Country:
Zip Code:
Contact Name:
Title:
Phone:
Fax:
E-Mail:
I hereby authorize and request Southeastern Louisiana University to initiate credit entries and if necessary, and 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 The electronic payment is to remain into effect until withdrawn by written notification to the University.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 – Please check the appropriate box to indicate if the payments you receive are deposited in a U.S. Financial Institution and
transferred to an account outside the United States. Yes means receipts are transferred outside the U.S. No mean receipts are not
transferred outside the U.S.
Signature below signifies the acceptance of the above terms and conditions:
__________________________________________
________________________________
Signature
Job Title
To be complete by Accounts Payable personnel:
Vendor# _________________
Date: _________
Entered by: _______________
__________________
Date