Electronic Funds Transfer Form

Electronic Fund Transfer Application

Please complete the following form to authorize electronic fund transfer.

Retail Partner Information

Company Name*

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Address*

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City*

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State*

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Zip Code*

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Phone*

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Buyer/Contact Name*

Please let us know your name.

Buyer/Contact Email*

Please let us know your email address.

Buyer/Contact Phone*

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Bank Information

Bank Name*

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Bank Address*

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Bank City*

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BankState*

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Bank Zip*

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Bank Contact Name*

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Bank Contact Phone*

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Bank Contact Fax*

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Bank Account Number*

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Bank ABA Routing Number*

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Retail Portal Access Setup Form

The BudPayments.com website is a self-service tool in which summary and invoice level payment information is accessible for A-B wholesaler deliveries. If you would like to gain acess to this site, please complete the information below.

Retailer Name

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Name of User

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User Email Address

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User Address

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User City

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User State

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User Zip Code

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User Phone

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Authorization

Authorization*

Yes! I authorize Terrance A. Smith Distributing to use the information submitted for electronic funds transfer. Invalid Input

Please attach an image of a voided check

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