Nevada Nurse Apprentice Program

Nevada Rural Hospital Partners Foundation

Nurse Apprentice Program ARPA Grant 


Bank EFT Account Request

 

Hello , Thank you for submitting your bank information, we will be enrolling you in our US Bank EFT system.

Name of Facility:  

Name of Person Authorizing: , Email : , Phone Number:  

Bank Name:

Bank APA Routing Number:   

Bank Account Number:  

Bank Account Type:  

You have provided validation via an uploaded deposit slip or voided check as attached here :  

I, the undersigned, represent that I am duly authorized to represent and that I agree the information provided is accurate and complete.

 

Leave this empty:

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Signature Certificate
Document name: {{gravity-field-id-1}} - Bank EFT request
lock iconUnique Document ID: ebc80163e3ee7a803fee4c80b7c5545388902e96
Timestamp Audit
June 3, 2022 2:36 pm PST{{gravity-field-id-1}} - Bank EFT request Uploaded by Todd Radtke - todd@nrhp.org IP 134.197.230.99
June 15, 2022 9:31 am PSTAnn Murdoch - ann@nrhp.org added by Todd Radtke - todd@nrhp.org as a CC'd Recipient Ip: 134.197.230.99
June 15, 2022 9:47 am PSTAnn Murdoch - ann@nrhp.org added by Todd Radtke - todd@nrhp.org as a CC'd Recipient Ip: 134.197.230.99
June 15, 2022 10:07 am PSTAnn Murdoch - ann@nrhp.org added by Todd Radtke - todd@nrhp.org as a CC'd Recipient Ip: 134.197.230.99
June 15, 2022 10:58 am PSTAnn Murdoch - ann@nrhp.org added by Todd Radtke - todd@nrhp.org as a CC'd Recipient Ip: 134.197.230.99