910 Douglas Pike Attn: Accounts Payable Smithfield, RI 02917 401-459-6000	EFT PAYMENT ENROLLMENT FORM For prompt payment please email all invoices to accountspayable@nhpri.org Any questions should be directed to the email above

APPLICATION REQUEST TYPE: ☐ New applicaton ☐ revised application

PAYEE/COMPANY INFORMATION
Taxpayer ID (required) – Attach copy of most recent W9 – Must be signed within the last 3 years	Click here to enter text.
Name (As it appears on W9-Box 1-IRS Name):	Click here to enter text.
Check Payable to/Business Name (Box 2 on W9 if different from Box1):	Click here to enter text.
Primary Address (W9)	Click here to enter text.
Payment Remit To Address: (if different from Primary)	Click here to enter text.
Contact Name:	Click here to enter text.
Phone Number:	Click here to enter text.
Remittance Email Address:	Click here to enter text.

FINANCIAL INSTITUTION INFORMATION
Bank Name:	Click here to enter text.
Nine-Digit Routing Number:	Click here to enter text.
Account Number:	Click here to enter text.
Type of Account:	☐Checking Attach voided check or letter from bank institution ☐Savings

Name & Title of Payee or Authorized Official (please print): Click here to enter text.
Signature of Payee or Authorized Official (required):	Date:

Send this form, voided check and W9 to:
Fax: (401) 459-6043	Secure email: accountspayable@nhpri.org