| New Revised |
| Employee Information |
Name:
|
Address 1:
|
Address 2:
|
City:
| State/Province:
| Zip/Postal Code:
|
| Banking Information |
| Checking Account Only-Direct Deposit |
Bank Name
|
Account No.
|
Routing No.
|
| Savings Account Only-Direct Deposit |
Bank Name
|
Account No.
|
Routing No.
|
| Please reimburse me with a check and not through direct deposit. |
|
| Authorization |
I Accept
(checking the checkbox above is equivalent to a handwritten signature)
|
When you receive your first direct deposit remittance advice, you may want to check with your bank to ensure there was not a problem with the transmission. |