DEALER PAYMENT REQUESTWe use this form to collect contact information for the person at your company responsible for receiving and managing project-related invoices, so we know who to send them to and follow up with as needed.Company InformationBusiness Name(Required) Primary Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Contact Name(Required) First Last Primary Contact Email(Required) Primary Contact Phone(Required)Accounts Payable Contact NameIf different from Primary Contact First Last Accounts Payable Contact EmailIf different from Primary Contact Email Accounts Payable Contact PhoneIf different from Primary Contact PhoneSpecial NotesPlease let us know if there's anything particular we should be aware of.Bank ACH Information(If Applicable)Bank Name Bank Branch Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Bank 9-digit Routing Transit Number(ABA Number) Bank Account Number Type of Account Checking Savings Approval/AuthorizationI 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 opportunityCheck here to agree & authorize:(Required) Name of Authorized Official(Required) Title of Authorized Official(Required) Today's Date(Required) Month Day Year