EFT Payment Authorization T H E • C I T Y • O F
COPPELL
CITY OF COPP'FLL
Electronic Funds Transfer (EFT) Payment Authorization
City of Coppell Account Number:
(the account number or customer number your company has assigned us)
Vendor Name:
Vendor Address:
Vendor Contact:
Vendor Phone Number:
Vendor Email for ACH
payment notification:
Please fill in the checking account information below for EFT payment:
L New EFT set-up L Bank Change
Local Depository Bank:
Bank City/State:
Bank Telephone Number:
Bank Routing Number (9 digits):
Bank Account Number:
Authority is hereby given to the City of Coppell (Coppell)to initiate credit entries to the account shown above
for any payments the Vendor authorizes Coppell to credit through electronic funds transfer.
The person executing this Agreement on behalf of Vendor represents that he or she has the authority to
authorize the credit to the above account on behalf of Vendor and that all necessary administrative
procedures, policies, and laws prerequisite have been complied with. This authority shall remain in full force
and effect until the City of Coppell receives written notification of a change.
Name of Authorized Representative(printed) Telephone Number
Signature of Authorized Representative Date
ALL FIELDS MUST BE COMPLETED FOR THIS DOCUMENT TO BE VALID
REV. 3/2013