This form authorizes Denton County Emergency Services District No. 1 (“District”) to issue vendor payments via Automated Clearing House (ACH) Electronic Funds Transfer (EFT) instead of paper checks.

Electronic payments improve payment security, reduce check fraud risk, and speeds up payment processing.

Legal Name (required)

DBA/Trade Name

Physical Street Address (required)

City (required)

State (required)

Zip (required)

Contact Name (required)

Contact Email (required)

Contact Phone (required)

Bank Name (required)

Routing Number (required)

Account Number (required)

Account Type (required)

Checking

Savings

Remittance Email (required)

Please upload a Voided Check or Bank Letter Confirming Routing and Account

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I authorize Denton County Emergency Services District No. 1 to deposit payments via ACH Electronic Funds Transfer to the account listed above. I certify that I am authorized to approve electronic payments for this vendor and that the information provided is accurate.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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The District encourages electronic payment to improve efficiency and reduce risk associated with paper check fraud.