Vendor Setup and Change Form
Africa Central Area
Return a scan of the completed form by email to the Church Representative. For current/cheque accounts
attach a cancelled cheque or bank letter. For Savings accounts, attach a bank statement or bank letter.
Vendor Information New Vendor Change to Existing Vendor Employee or Volunteer
Vendor's name Tax number VAT number
Street address (number, street, plot and apartment or suite number) Suburb City Postal Code Country
Contact person's name Phone (with area code) E-mail address to receive notice of payments
Authorised vendor representative Phone (with area code) E-mail address
Description of goods or services provided Payment terms Currency
Sales Rental Service School Other (describe):
Please disclose relationships or other circumstances that might create a conflict of interest between Vendor and any affiliate of The Church of Jesus
Christ of Latter-day Saints.
Select all that apply: Name of Employee When
I am/have been, or any member or representative of my company is/has been, an employee of the Church.
I am related to an employee or former employee of the Church.
Explanation:
Electronic Funds Transfer Agreement
I request payment by electronic funds transfer (EFT) according to the following terms:
1. Buyer will make EFT payments to the financial 4. Buyer can adjust future payments if (a) payments made previously are
institution and account number I have provided below. found to be duplicates, excessive, or in error or (b) there is any other
2. I acknowledge that I must make changes in enrollment basis for adjustment under an agreement of the parties.
information in writing at least 14 days prior to the 5. Buyer is not responsible for any loss arising from error, mistake, or fraud in
effective date. the information I provide or from a loss of data caused by the actions of
3. Payments will be considered made when my financial another.
institution has received or has control of the payment 6. Either party may terminate this agreement upon 14 days written notice.
(which may not coincide with posting to my account). 7. This agreement does not change the rights and obligations contained in
any negotiated agreement. Such agreement prevails.
Bank name Currency of account Name on bank account
Branch number Bank account number NIB number (if applicable) RIB (if applicable)
Swift code IBAN number (if applicable) Bank account type
Checking Savings
As an authorized vendor representative, I declare that the information provided in this form is correct and I agree to be bound by the terms and
agreements included herein.
Vendor Signature Printed name Title Date
Church Use Only To be completed by the Church representative requesting vendor action Vendor ID:
Name of requesting department, Mission, FM Group, etc. FM Group Other Area Tax Withholding Code (if applicable)
Mission Department
Estimated total vendor payments per annum in USD*:
*Note: Additional information and documentation may be needed if total per annum payments exceed $10,000.
For more information, select the following link: Vendor Level Information
I declare that to the best of my knowledge, this vendor is needed and qualified, that the information provided is accurate, and that any relationships or
other circumstances that might create a conflict of interest between Vendor and any affiliate of the Church have been disclosed and resolved.
Church representative signature Printed name Title Date
Note: To complete vendor setup or modification, send a scan of this completed form by e-mail to [email protected]
International English Version of PD50027868-Uncorrelated
