Vendor ACH Authorization Form

V P Holdings / Valpak Direct Marketing Systems / Valpak Franchise Operations
805 Executive Center Drive West, Suite 100, Saint Petersburg, FL 33702

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CONTACT INFORMATION

Business Name

Address

City

State

Zip / Postal Code

Federal ID Number

Contact Person

Title

Phone Number

Fax number

BANK INFORMATION

Name of Financial Institution

Address of Financial Institution

Bank Routing Number

Confirm Bank Routing Number

Bank Account Number

Confirm Bank Account Number

Account Type

Checking Account
Savings Account

REMITTANCE INFORMATION

E-mail remittance advice to:

AUTHORIZATION

I authorize V P Holdings or subsidiaries and the financial institution listed above to electronically deposit invoice payments into my bank account. If monies to which I am not entitled are deposited into my account by V P Holdings or subsidiaries, I authorize V P Holdings or subsidiaries to direct the bank to return said funds. This authorization will remain in effect until it has been cancelled in writing.

Authorized Signature

Title

Date