Payment Option Form
Chapter Name and Number:
Faculty Sponsor Name:
Email: _____________________________________________ Date:
Chapter Officer Name:
_____ Email:
Please check the box of the option you prefer and complete the appropriate information:
Electronic Funds Transfer
If this option is chosen, please provide the following:
Account Name
Account Number
Bank Name
ABA Routing Number (for U.S. accounts)
Swift Number (for non-U.S. accounts)
IBAN Number (for European accounts)
Currency Accepted (for non-U.S. accounts)
Branch location
Check (issued in US dollars only)
Address (check will be mailed to this address):
Hold Funds on Account
IMPORTANT:
* All payment requests must be emailed by a chapter officer with the Faculty Advisor copied.
* If necessary to transfer the funds more than twice a USD 25 penalty fee will be deducted for the
third transfer.
Please return this form to chapters@spe.org