rbank detail change:payment method change - …vendors.phillips66.com/en/payment/documents/ach...
TRANSCRIPT
canavs
Stamp
canavs
Text Box
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENT
canavs
Text Box
VENDOR INFORMATION
canavs
Line
canavs
Text Box
VENDOR NAME (“VENDOR”)
canavs
Line
canavs
Text Box
PHILLIPS 66 VENDOR NUMBER
canavs
Line
canavs
Line
canavs
Text Box
REMIT ADDRESS ON INVOICE
canavs
Text Box
CITY
canavs
Line
canavs
Line
canavs
Line
canavs
Text Box
STATE
canavs
Text Box
ZIP
canavs
Text Box
ACCOUNTING / EFT CONTACT NAME
canavs
Line
canavs
Line
canavs
Text Box
TELEPHONE
canavs
Line
canavs
Text Box
FAX NUMBER
canavs
Line
canavs
Text Box
IRS TAXPAYER ID (FEIN)
canavs
Line
canavs
Line
canavs
Line
canavs
Line
canavs
Line
canavs
Text Box
NACHA PAYMENT FORMAT (PLEASE CHECK SELECTION):
canavs
Text Box
CTX ____ (No payment advice from Phillips 66) CCD ____ (Payment advice from Phillips 66)
canavs
Text Box
CTX FORMAT TRANSMITS REMITTANCE DETAIL VIA EDI, CCD DOES NOT
canavs
Text Box
FAX NUMBER FOR REMITTANCE ADVICE (CCD OPTION ONLY):
canavs
Text Box
E-MAIL ADDRESS FOR REMITTANCE ADVICE (CCD OPTION ONLY):
canavs
Text Box
BANKING INFORMATION
canavs
Line
canavs
Text Box
BANK NAME
canavs
Text Box
BANK ROUTING NUMBER
canavs
Line
canavs
Line
canavs
Text Box
BANK ACCOUNT NUMBER
canavs
Line
canavs
Line
canavs
Line
canavs
Line
canavs
Text Box
ADDRESS
canavs
Text Box
PHONE
canavs
Text Box
BANK ACCOUNT TYPE
canavs
Text Box
CHECKING ____ SAVINGS ____
canavs
Text Box
MONEY MKT ____
canavs
Line
canavs
Line
canavs
Line
canavs
Line
canavs
Text Box
CITY
canavs
Text Box
STATE
canavs
Text Box
ZIP
canavs
Text Box
BANK CONTACT NAME
canavs
Line
canavs
Line
canavs
Text Box
Above named Vendor hereby authorizes Phillips 66 Company and subsidiaries of Phillips 66 Company (collectively, “Phillips 66”) to originate Automated Clearing House electronic funds transfer (EFT) credit entries to Vendor's account, as indicated below, for payment of goods and/or services.
canavs
Text Box
Vendor acknowledges and agrees that the terms and conditions of all agreements with Phillips 66 concerning the method and timing of payments for goods and services shall be amended as provided herein. Vendors whose previous payments were remitted via check will receive funds via ACH three (3) calendar days after due date on invoice. If payment date falls on a weekend or holiday, funds will be deposited the following business day. Vendor shall be responsible for any loss which may arise by reason of any error, mistake or fraud regarding the information Vendor has provided in this agreement. Vendor may change any portion of the information provided under Bank Information by giving at least thirty (30) days written notice to Phillips 66 at the address show below. The authority shall remain in effect until fifteen (15) days after Financial Institution, at address shown above, and Phillips 66, at the address shown below, have received written cancellation from Vendor. Notice of cancellation shall in no way affect credit or debit entries initiated prior to actual receipt and processing of notice. Vendor understands that Phillips 66 may suspend this Agreement at any time. By signing this Authorization, Vendor in no way relinquishes any legal right to dispute any item.
canavs
Text Box
________________________________ ________________________________ ________________________________ ____________________ AUTHORIZED NAME AUTHORIZED SIGNATURE TITLE DATE Digital Signature Acceptable
canavs
Text Box
VENDOR AUTHORIZATION:
canavs
Line
canavs
Text Box
FOR PHILLIPS 66 INTERNAL USE
canavs
Line
canavs
Text Box
Date:
canavs
Line
canavs
Line
canavs
Line
canavs
Line
canavs
Text Box
Contact Name:
canavs
Text Box
Title:
canavs
Text Box
Contact's Phone Number:
canavs
Text Box
Contact's Email Address:
canavs
Text Box
Contact Attempts:
canavs
Text Box
Bank Detail Change:
canavs
Text Box
Payment Method Change:
canavs
Text Box
Email Sent:
canavs
Text Box
Email Received:
canavs
Text Box
User ID:
canavs
Line
canavs
Line
canavs
Line
canavs
Text Box
Time:
canavs
Line
canavs
Line
canavs
Line
canavs
Line
canavs
Line
canavs
Line
canavs
Line
canavs
Text Box
Please return this form along with a voided check (for the above account number only) to your Phillips66 representative below: Phillips 66 Company Attn: Vendor Master AB 353 Bartlesville, Oklahoma 74004 Fax: 918-977-9416
canavs
Rectangle
canavs
Text Box
OR