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<br /> <br /> <br />Non-Professional Services Agreement between 1/16/2025 <br />City of San Leandro and ParkMobile, LLC Exhibit D Page 1 of 2 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />CLIENT ELECTRONIC FUNDS AUTHORIZATION FORM <br /> <br />This form authorizes ParkMobile, LLC to make payment to a business electronically. All <br />payments will be paid in the account designated by the voided check or bank letter attached <br />to this form once it has been verified by ParkMobile, LLC via telephone call, otherwise a <br />check will be issued to the address on file. It is the responsibility of the client to notify <br />ParkMobile, LLC of any changes pertinent to electronic payments, such as changes in banking <br />information or email address. <br /> <br />PAYEE/CLIENT INFORMATION <br /> <br />CLIENT NAME: <br />ADDRESS: <br />CONTACT PERSON: <br />TELEPHONE NUMBER: <br />VERIFICATION CALL BACK CONTACT PERSON: <br />VERIFICATION TELEPHONE NUMBER: <br />PRIMARY FINANCE CONTACT EMAIL: <br />SECONDARY FINANCE CONTACT EMAIL: <br />SIGNATURE & TITLE OF AUTHORIZED OFFICIAL: <br /> <br />FINANCIAL INSTITUTION INFORMATION <br /> <br />BANK NAME: <br />ADDRESS: <br />CONTACT PERSON: <br />TELEPHONE: <br />EMAIL: <br />NINE DIGIT ROUTING TRANSIT NUMBER: <br />Docusign Envelope ID: 6423E261-A28E-4FC2-BFD8-12CA98036230