ACH Transmittal Form

Revised 040323

Please fill out your information below.

Name (Vendor):

Address: ____________________________________________________________________________

City: _________________________________ State: _______________ Zip: __________________

Bank Name: _________________________________________________________________________

Bank Address: _______________________________________________________________________

Account Type: Checking Savings

Routing Number: ______________________________ Account Number: ______________________

Email Address for Payment Information (list one): ____________________________________________

Contact Name & Phone: ________________________________________________________________

Printed Name & Title: __________________________________________________________________

Signature: ___________________________________________________________________________

Phone Number: _______________________________________________________________________

Important Vendor information regarding our ACH process:

Please be advised that there are occasions when your company may issue a credit memo to Western

Michigan University. In order for the system to work

properly please make sure that your bank account is

able to accept both credit and debit ACH transactions (we would never send a debit without a credit). If

your company or bank does not allow/want debits (credit memos) transmitted via ACH please indicate that

you are not interested at this time.

Please mail this form along with a letter on company letterhead including your banking information to:

Western Michigan University

Accounts Payable

1903 W. Michigan Ave

Kalamazoo, MI 49008-5208

For WMU use only:

I, (print name)

have verified the banking information via a phone call

with the supplier and confirm the banking information details are accurate.

epartment:

Signature:

Phone:

Date