Supplier Account

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					(Supplier Company Letterhead)

                                     Electronic Funds Transfer Authorization
To Be Completed by Supplier (Please Type):

Supplier Name:                                                        EFT Contact Person:

Supplier Address:                                                     EFT Contact Phone Number:

City:                                                                 EFT Contact E-Mail Address:



Type:                           Initial Electronic Funds Transfer Authorization
                                Change in Electronic Funds Transfer Authorization

Supplier Bank Account Information (Completed by Supplier):

Name of Bank                                                          Bank Account Number

City of Bank                                                          Bank Transit Number (9 digits)

State of Bank

By signing below the Supplier agrees to participate in the GHSP Electronic Funds Transfer payment program. The supplier also
authorizes that future payments to their company should be made according to the Supplier Bank Account Information supplied above.

Financial Officer's Signature (Date)

Financial Officer's Name (Please Print)


Bank Verification (Completed by Supplier's Bank):

The Bank Account Information as documented above by the supplier is correct for the Supplier Name referenced above.

____________________________________                                  ____________________________________
Bank Officer's Signature     (Date)                                   Title

____________________________________                                  (     )-           -
Bank Officer's Name     (Please Print)                                Phone Number

Mail Completed Form to:                                               Under the GHSP Electronic Funds Transfer program, GHSP will
GHSP, Inc.                                                            direct its bank to deposit payments generated weekly according
Accounts Payable                                                      to the payment terms on the GHSP purchase order on the
1250 South Beechtree St.                                              following Monday. In the event Monday is not a business day for
Grand Haven, MI 49417                                                 the bank, the deposit will be made on the following business day
                                                                      of the bank.

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Description: Supplier Account document sample