Direct Deposit ACH Authorization Form

Employee Information
First Name:_______________________________ MI ______ Last Name_____________________
Address
______________________________________________________________________
City_________________________ State___________________________________ Zip ____________
Email Address ________________________________________________________________________
Home Phone (include area code) _____________________________________
Cell Phone (include area code) _______________________________________

I wish to receive my payroll checks by Direct Deposit. I hereby authorize The ______________________________ to originate electronic credit transactions to my bank (or credit union or savings & loan) account indicated below. If necessary, The ______________________________ may make deductions from my account for any payments credited to my account in error. This authority is to remain in full force and effect until the ______________________________ has received written notification from me of its termination in such time as to afford The ______________________________ and my bank a reasonable opportunity to act on it.
Bank: __________________________________________________________________
Routing #: _______________________________________________________________
Account Number #:________________________________________________________
Type of Account: _______Checking ______Savings
Signature: ________________________________________________________________
Date: ____________________________________________________________________

DIRECT DEPOSIT ACCOUNT VERIFICATION
Please attach a void check or deposit slip in this area so that we may verify your routing and account numbers.