ACH Originator Pre-Qualification Application

Company Name

Mailing Address

City

State/Province

Zip/Postal

Physical Address (if different)

City

State/Province

Zip/Postal

Company Telephone Number

Company Fax Number

Operations Contact Name and Title

Telephone Number

Email

Business Type (check one)

Corporation

Partnership

Sole Proprietorship

OtherOther

Date Business Established

Employer (Tax) ID Number

Type of Business

Date of Incorporation

State of Incorporation

Do you have an existing deposit or loan account relationship with Bank of Bridger, N.A. or any branch?

Yes

No

If Yes, check any of the following documents which are already on file with the financial institution:

Corporate Resolution or Partnership Agreement

Prior Year Tax Return Copy (signed and dated)

Copy of Financial Statements (signed and dated)

Credit References

Does the company currently originate ACH transactions?

Yes

No

No. of ACH Files monthly:

Dollar volume of ACH Files monthly: ($)

No. of ACH Transactions monthly:

No. of ACH Returns Monthly:

Dollar volume of ACH Returns monthly: ($)

Estimated no. of ACH files monthly:

Est. monthly dollar volume: ($)

Est. no. of ACH Transactions monthly:

Max amount of any ACH File: ($)

Max amount of any ACH Transaction: ($)

What type of ACH files will be sent?

ACH Credits - Other (please explain)

ACH Debits - Other (please explain)

What is the Account Number for your account that will be used for Settlement?

What will be the frequency of ACH files sent?

Weekly on:

Bi-Weekly on:

Monthly on:

Other Frequency (please explain)

What type of ACH transactions will be sent?

PPD (Consumer)

CCD (Corporate)

OtherOther

Company Official Name and Title:

Date Submitted:

By submitting this form, the Company grants permission for the financial institution to obtain credit information from reporting agencies.

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