Attach Voided Check. V5. SCHEDULED PAYMENTS -------------------------------------------------------------------------------- You may select either ISA/EFT or MCB. ISA Number [ ] [ ] [ ] [ ] ELECTRONIC FUNDS TRANSFER (ISA/EFT) You must attach a voided check. Select one: [ ] MONTHLY [ ] QUARTERLY [ ] SEMI-ANNUALLY [ ] ANNUALLY Amount Date of First Draft | | |$ | __________________________________________________________________ Bank Transit Number Checking/Savings Account Number | | | | __________________________________________________________________ Bank Name [ ] CHECKING | [ ] SAVINGS | _____________________________________________ BANK ACCOUNT OWNER - Select one: [ ] ANNUITANT [ ] OTHER- Enter information below: Name: First, MI, Last Sex Birthdate: mm-dd-yyyy | | | | | | ______________________________________________________________________________ Street Address City, State, Zip | | | | ______________________________________________________________________________ Taxpayer ID Number Daytime Telephone Number | | | | ______________________________________________________________________________ Signature below is authorization to the depository institution specified above to pay and charge named account with electronic funds transfers, or other form of pre-authorized check or withdrawal order transfers, initiated by the Northwestern Mutual Life Insurance Company to its own order. This authorization will remain in effect until revoked in writing. X __________________________________________________________ Signature of Bank Account Owner [ ] MULTIPLE CONTRACT BILL (MCB) Amount MCB Number MCB Payer Name | | | |$ | | ______________________________________________________________________________ 46 -------------------------------------------------------------------------------- SIGNATURES - VARIABLE ANNUITY -------------------------------------------------------------------------------- THE ANNUITANT CONSENTS TO THIS APPLICATION. EACH PERSON SIGNING THIS APPLICATION DECLARES THAT THE ANSWERS AND STATEMENTS MADE IN THIS APPLICATION ARE CORRECTLY RECORDED, COMPLETE AND TRUE TO THE BEST OF HIS OR HER KNOWLEDGE AND BELIEF.
Attach Voided Check. HERE (Neither a temporary check nor a deposit slip is acceptable.) For savings account, see “Savings Account” on the back of this form. FOR PAYROLL DEPARTMENT USE ONLY Date Received: ❑ Eligibility OK Effective Date: ❑ Not Eligible (3 pay periods from date processed) Cancellation Date: Account Number: Bank transit/ABA number Check only one: ❑ CHECKING ❑ SAVINGS Processed by: date: White: Payroll Gold: Employee MIS 010 (06/09) INFORMATION ABOUT DIRECT DEPOSIT FOR EMPLOYEES ELIGIBILITY REQUIREMENTS Employees who are paid each pay period during the school year are eligible for direct deposit.
Attach Voided Check. The Merchant agrees to abide by the terms & conditions contained in the Merchant Processing Agreement signed on , provided, however, that the term of the Merchant Processing Agreement relating to the above-referenced Additional Location shall be for the same length of time as the initial Term (defined in the Merchant Processing Agreement), and such Initial Term for the Additional Location shall commence on the date signed by Officer/Owner, indicated below. Printed Officer/Owner Name Signature Title Date CORE - MERRICK LOCATION ADDENDUM PRIMARY MERCHANT INFORMATION: Location No: 2 Date: Legal Name: City of Richmond Bank Chain: 204622 Main Contact: Title: Accounting Manager Merchant Number: (Assigned Upon Approval) LOCATION INFORMATION: Sales Rep :Xxxxx Xx Xxxxx 1130 DBA: City of Richmond Web Location Address: 000 Xxxxx Xxxxxx Xxxxx Mailing Address: PO Box 4046 Customer Service Phone Number: (510) Main Contact: Statement DBA (23 Chr.): City of Richmond Web SIC: 0000 Xxxx: Xxxxxxxx XX: XX Zip: 00000 Xxxx: Xxxxxxxx XX: XX Zip: 94804 000-0000 Phone #: (000) 000-0000 Fax #: (000) 000-0000 Title: Accounting Manager Email: Avg Ticket: $451.00 Max: _ Monthly Vol: $123,180.00 Swipe % 0 Keyed % 0 MOTO % 0 Internet % 100 Merchant Products or Services Offered (be specific): City Tax and Permits Terminal / Payment Application: iMS Version: Does Merchant Use Independent Servicer (store, maintain, or transmits cardholder data)? (if yes, provide the following) Servicer / Payment App. Manufacturer: BridgePay / iMS Software Phone: American Express (10 Digits): American Express Annual Volume: Program: Service Fees: Account Name: AMS*Service Fee MID: 730308296 Rate: 2.95% Service Fee with a $2.00 minimum per transaction SITE INFORMATION: Merchant Type: Internet Website Building Type: Office Building Area Zoned Commercial Square Footage: 2501 - 5000 Merchant: Owns Landlord: Contact: Phone: Fulfillment Co. Contact: Phone: This Location is Open for Business: Yes No Inspected By: Date: : Sell To: Business: 75 % Public: 25 % Marketing: Locally Does the Merchant Own Product/Inventory? Are Products Stored at the Business Location? If No, Where? YES YES Orders Processed by: Merchant If Processing Internet Transactions (Please Complete The Following) Cards Processed by: Merchant Internet transactions encrypted by SSL or Better? YES
Attach Voided Check. The Merchant agrees to abide by the terms & conditions contained in the Merchant Processing Agreement signed on , provided, however, that the term of the Merchant Processing Agreement relating to the above-referenced Additional Location shall be for the same length of time as the initial Term (defined in the Merchant Processing Agreement), and such Initial Term for the Additional Location shall commence on the date signed by Officer/Owner, indicated below.
Attach Voided Check. Check box if this is a revision to a previous agreement. Attach voided check. READ THIS When you begin direct deposit or make a revision to your direct deposit account, a pre- note authorization process takes place in order for your financial institution to validate your account. This process takes 3 to 4 days and funds are not direct deposited until this process is complete. During this period if there are any errors Payroll will contact you. Any changes to direct deposit must be received by Payroll 3 weeks prior to pay date. • In an effort to reduce the use of paper, direct deposit vouchers will not be printed. An e-mail informing you of your direct deposit will be sent to your D93 Google g-mail address, unless you are a substitute/summer helper, in which case it will be sent to the personal email account you have provided above. • Instructions on accessing your individual information on the IVisions Web Portal will be provided. • You may choose any financial institution and there is no cost for direct deposit. • Notify Payroll of any change in account number or financial institution to insure that funds are deposited to the correct account. • Notify Payroll of a change in ownership of your financial institution. • Notify Payroll of a change in your email address. • Your funds are available to you at 12:01 a.m. on any given payday. I hereby authorize the CCSD93 Payroll Department to direct deposit my paycheck. I have read this agreement and understand that it is my responsibility to access my individual direct deposit information through the IVisions Web Portal. Date: Signature: For Office Use Only Pre-note Date Live Date Email Name Uncheck Prenotification DD Activation and Set-Up
Attach Voided Check. By signing this form, you are agreeing to the terms noted within this membership agreement. Print Student Name (Parent/Guardian if under 18yrs of age) Signature of Student Date RATES, PAYMENTS and REFUNDS MEMBERSHIP PERIOD A membership period is defined as one (1) month. Memberships are automatically renewed every month unless cancellation is provided at least thirty (30) days prior to your membership renewal period. Kinetix Combat Sports & Fitness reserves the right to change membership fee schedules at any time.
Attach Voided Check. HERE (If withdrawing from a checking account): Employee Sending/Accepting Form Keyed Date Verified Pinellas Federal Credit Union 00000 Xxxxxxxx Xx, Xxxxx, XX 00000 | 727.586.4422 ||xxx.xxxxxxxxxxx.xxx Federally insured by NCUA Pinellas Federal Credit Union ACH Loan Payment Origination Agreemnent
Attach Voided Check. I hereby authorize the Los Angeles Police Federal Credit Union to initiate debit(s)/credit(s) (and/or corrections to the previous entries) to my account as indicated above. This authority will remain in full force and effect until I give LAPFCU written notification at least (3) business days prior to a scheduled transfer date. I agree that this account shall be governed by the terms and conditions of the LAPFCU Truth-in- Savings Disclosure and Agreement, and I acknowledge receipt of a copy of the Agreement. In addition, I agree to the following terms and conditions:
