WELCOME to the IPROMOTEU Vendor Electronic Payment Authorization Form.

iPROMOTEu currently has terms with your company and would like to set your company up on ACH.

By completing and submitting this form, I am acknowledging acceptance of the terms for payments from iPROMOTEu on behalf of it's affiliates.

Please enter number below

Vendor Terms

Bank Name

Bank Address

Address Line 1

Address Line 2

City

State

Zip Code

Routing Number:

Account Number

Company Name (Name On Account):

Address On Account

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

ACH Remittance Email Address:

Email

Confirm Email

Authorization: By selecting this checkbox, I hereby authorize iPROMOTEu to deposit funds into our account for the payment of goods and services.

Name:

Person who is filling out the form

Job Title

Person who is filling out the form

Contact Email:

Person who is filling out the form

Contact Phone:

Person who is filling out the form

Date / Time

Signature

Clear Signature