ELECTRONIC PAYMENTS ENROLLMENT FORM

VENDOR INFORMATION

Vendor Name

Address (street, city, reg, postal

code, country)

Remit Address
(if different from above)

Tel No. Fax No.

E-mail
E-mail (orders)
(remittance)

Currency
BANK INFORMATION FOR ELECTRONIC PAYMENTS
Account Type (select one): Checking account Savings account

Bank Name
Bank address(include country)

Bank Key/ ACH/ABA Routing/ EFT etc.

IBAN or Clabe (if applies)

Account No.

Account holder

SWIFT Code/ BIC No. (if applies)

VENDOR SIGNATURE
Completed by: STAMP

Manual
Signature:
Date:

V. 2017/08
CALLBACK PROCESS IN ROCKWELL AUTOMATION

Please be informed, if we receive any notification that your banking details have changed, we will contact your company directly to
confirm bank account number.

Due to numerous fraud attempts, banking information sent by email must be double-checked via phone. It is required to make sure
the banking details are correct, and we can provide them into our system before making a payment.

As Rockwell’s Global Finance Operations Department is located in Poland, please be aware that our employee - Marta Mroz
(mmroz1@ra.rockwell.com) - will call you from number: +48 32 778 12 41 (internal: 85241) to confirm the last five digits of bank
account number provided in documentation we have received from you.

VENDOR SIGNATURE
Completed by: STAMP

Manual
Signature:
Date:

V. 2017/08