Direct Deposit Authorization Form

EMPLOYEE ID#______________

EMPLOYEE NAME: ______________________________________

I hereby authorize ___________________ hereinafter called COMPANY, to initiate credit entries and, if necessary, debit entries for adjustments to my:

CHECKING #1

CHECKING #2

Savings #1

Savings #2

BANK/FINANCIAL INSTITUTION: ____________________________________

BANK/FINANCIAL INSTITUTION PHONE#: _____________________________

This agreement is to remain in effect until COMPANY has received written notification from me of its termination in such time to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Signed ____________________________  Date _____________

Please attach to this agreement:

·                    a check for checking account information

·                    a deposit slip for savings account information