PR-FRM-44 Rev 00a Authorization Agreement for Vendor Automatic Electronic Funds Transfer Form.doc

AUTHORIZATION AGREEMENT FOR

VENDOR AUTOMATIC ELECTRONIC FUNDS TRANSFER

Please print in ink or type:

FORMCHECKBOX

Initial Participation

FORMCHECKBOX

Cancel Participation

FORMCHECKBOX

Change of

Financial Institution

FORMCHECKBOX

Change of

Account Number

I hereby authorize ASRC Federal Holding Company and its Subsidiaries, hereinafter referred to as “the Company,” to initiate Electronic Funds Transfer, (EFT), credit entries or debit corrections or all amounts payable to me through the Company’s EFT program(s), and to the depository institution and account, identified below.

Vendor Name:

Financial Institution Name:

Branch Location:

Name on Account:

City:

State:

Zip Code:

Bank ABA/Trace No:

Account No:

Bank Branch Code:

Bank Swift ID (if exists):

Vendor Email Address (if exists):

Vendor Terms (i.e. NET 30):

This authorization is to remain in full force and effect until the Company has received proper written notification from me of its change or termination, or the Company terminates its EFT program or my participation therein.

AGREED AND ACCEPTED:

Signature:

Date:

Printed Name:

Title:

Signature:

Date:

Printed Name:

Instructions:

1.

Complete and sign this form.

2.

If a checking account, include a voided check and verify with your bank that the ABA NUMBER (usually the first 9 digits at the bottom of your check) and YOUR ACCOUNT NUMBER are appropriate for direct deposit purposes.

3.

Business accounts require all bank signatures necessary to be on this form. If additional lines are needed, please attach an additional sheet.

4.

Send completed, signed form and voided check to ASRC Federal Holding Co., Procurement Department Vendor.Requests@asrcfederal.com 5.

If you have any questions, please email ASRC Federal Accounts Payable at apworkflow@asrcfederal.com ASRC Federal Use Only:

Vendor ID:

Remit Code:

Form Completed By:

Date:

Phone:

Please Staple Voided Check Here

PR-FRM-44 Rev. 00a 11/20/19