Direct Deposit / ACH Payment Authorization Form

Direct Deposit / ACH Payment Authorization Form
This is a

New EnrollmentChange
Vendor/Payee Name
Vendor/Payee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Name
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Account

CheckingSavings
ABA/Routing Number
Bank Account Number
Primary Contact Name

First NameLast Name
Primary Contact Phone Number
Please enter a valid phone number.
Primary Contact Email
example@example.com
I hereby authorize Baton Rouge Community College Foundation to initiate direct deposit entries (credit entries) and, if necessary, debit entries and adjustments for any credit entries made in error, to my account at the financial institution and account indicated above. This authorization will remain in effect until I provide written notification to terminate this agreement and allow reasonable time for processing.

I certify that I am an authorized signer on the account listed above and that the information provided is accurate. I understand that this authorization replaces any previous direct deposit instructions.
Signature

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