7.01 Dealer Markup Enrollment Form

DEALER MARKUP ENROLLMENT

We use this form to ensure we have accurate financial information on file should we be paying your company out any dealer markup.

Payee/Company Information

Vendor Name(Required)

Vendor name must match the name on your bank account.

DBA

Primary Address(Required)

Street Address Address Line 2 City State ZIP Code

Remittance Address

Only needed if different from your Primary Address

Street Address Address Line 2 City State ZIP Code

Contact Person Name(Required)

First Last

Contact Person Email(Required)

Would you prefer to receive payment via physical check mailed to the Primary Address listed above?(Required)

Yes

Bank ACH Information

Required if ACH payment is preferred

Bank Name

Bank 9-digit Routing Transit Number

(ABA Number)

Bank Account Number

Type of Account

Checking

Savings

Approval/Authorization

I certify that the information provided on this form is correct, and I hereby authorize Light Can Help You Accounts Payable to electronically deposit payments to the bank account designated above. It is my responsibility to notify Light Can Help You AP immediately if I believe there is a discrepancy between the amount deposited to my bank account and the amount of the invoice(s) paid. I understand that I must notify Light Can Help You AP in writing immediately of any changes in status or banking information. I understand that this authorization will remain in full force and effect until Light Can Help You AP has received written notification requesting a change or cancellation and has had reasonable opportunity to act on it, which should take no longer than seven (7) to ten (10) business days.

Name of Payee (or Authorized Official)(Required)

Title of Payee (or Authorized Official)(Required)

Today's Date(Required)