Vendor Settlement Authorization Application Form
Please fill out this form to authorize vendor settlement.
Applicant's Full Name
*
First Name
Last Name
Vendor Name
*
Vendor Contact Email
*
example@example.com
Vendor Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Settlement Amount (USD)
*
Settlement Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Settlement
*
Applicant Signature
*
Submit
Should be Empty: