FLORIDA POLYTECHNIC UNIVERSITY
FINANCE & ADMINISTRATION SUPPLIER MANAGEMENT
4700 RESEARCH WAY LAKELAND, FLORIDA 33805
(863) 874-8418 ADDSUPPLIER@FLORIDAPOLY.EDU
ELECTRONIC PAYMENT AUTHORIZATION
FEDERAL TAX IDENTIFICATION NUMBER
CHECK ONE EIN SSN
BUSINESS NAME OR PAYEE
CITY STATE ZIP
TELEPHONE FAX
NO
BANKING ACCOUNT INFORMATION
BANK NAME
ACCOUNT #
BANK CODE
BANK INSTRUCTIONS
ACCOUNT TYPE
BRANCH CODE (SWIFT CODE)
BRANCH NAME NAME ON ACCOUNT
I HAVE ATTACHED THE FOLLOWING BANKING ACCOUNT VERIFICATION AS REQUIRED
VOIDED CHECK OR SIGNED LETTER FROM BANK LISTING ACCOUNT INFORMATION
AGREEMENT
I H
EREBY AUTHORIZE AND REQUEST FLORIDA POLYTECHNIC UNIVERSITY TO INITIATE CREDIT ENTRIES AND,
IF NECESSARY, A DEBIT ENTRY IN ACCORDANCE WITH NACHA RULES REVERSING A CREDIT ENTRY MADE
IN ERROR, TO MY ACCOUNT AT THE FINANCIAL INSTITUTION NAMED. THE ELECTRONIC PAYMENT DATA
REMAINS IN EFFECT UNTIL AN ELECTRONIC PAYMENT AUTHORIZATION CHANGE HAS BEEN SUBMITTED.
NAME OF PERSON COMPLETING FORM
SIGNATURE OF PERSON COMPLETING FORM
EPA VERSION 2
CHECKING SAVINGS
REQUIRE PRENOTIFICATION
YES NO
START STOP CHANGE OF INFORMATION (INCLUDE W9) NAME CHANGE ONLY (INCLUDE W9)
FOREIGN SUPPLIERS ONLY
ADDRESS (NUMBER & STREET)
EMAIL EFT PAYMENTS NOTIFICATIONS
EMAIL ADDRESS FOR EFT PAYMENT NOTIFICATIONS
BANK IDENTIFICATION CODE
TRANSIT ROUTING NUMBER OF YOUR FINANCIAL INSTITUTION
NAME PROVIDED MUST MATCH THE W-9 SUBMITTED
BUSINESS INFORMATION
YES
COUNTRY
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