Mobotrex Inc CIQ 10.03.2024Authorization Agreement for Direct Deposit I (we) hereby authorize the City of Denton to deposit my payments into the checking account listed. The authority remains in effect until the City of Denton has received written notification from me of termination in time to allow reasonable opportunity to act on it, or until the City of Denton has sent me written notice of termination of the agreement. _________________________________ Vendor Signature _________________________________ Print Name/Title _________________________________ Date Vendor Information Please select one: □ New Request □Change Request____________________ Vendor Number (located on check detail) ___________________________________Vendor Name ___________________________________ TIN or SSN (Social Security Number) (required for verification, must match the number on file) ___________________________________ Mailing Address (where current check is mailed) _____________________ __________ City State ________________ Zip __________________________ Vendor Phone Number __________________________ Vendor Fax Number (optional) ___________________________________ e-mail address (required)___________________________________ Accounts Receivable Contact Name Banking Information ___________________________ Name of Bank Checking Account ___________________________________ Bank Name ______________________ __________ City State Enclose a voided Check or Deposit Slip, if available. ___ ___ ___ ___ ___ ___ ___ ___ ___ ABA Routing Number (Nine digit number listed on the bottom left side of your check) ____________________________________Checking Account Number Check Detail: A Report in a PDF format will be e-mailed to you. You must provide a valid e-mail address. If you need to change your e-mail address, please contact our Vendor Inquiry Hotline in Purchasing at : 1 (940) 349-7100 Or Purchasing@cityofdenton.com All fields are required MoboTrex, LLC109 West 55th St., Davenport IA36-2656899Kateri Miller-Morrisar@mobotrex.com563-323-000952806MoboTrex, LLCQuad City Bank & TrustBettendorfIA0 7 3 9 0 2 2 3 23675030Kateri Miller-Morris10/04/2024
MoboTrex, LLC