Southern Foundation - Authorization for ACH/EFT

Southern Univeristy School of Nursing

Pinning and Awards Ceremony Scholarship
Payee Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
U Number*
Example: U01234567
Full SS Number*
Full SS Number - Example: ###-##-####
SUS Email Address*
Personal Email Address *
example@example.com
Bank Information
Bank Name*
Branch Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
Bank Routing Number (ABA#)*
Checking Account Number*
Authorized Signature: By executing this document, I authorize the Southern University System Foundation to deposit all payments into the account listed below. Attached to this form are a completed authorization for disbursement form and supporting documentation; e.g., original invoices, original receipts, contracts, etc *

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