Company Information

Important! Please read and sign before completing and submitting.

I hereby voluntarily authorize the Company named above (hereafter “Employer”), either directly or through its payroll service provider, to deposit any amounts owed me, by initiating credit entries to my account (s) at the financial institution (s) of my choice (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Employer, either directly or through its payroll service provider, to my account. To the extent permitted by law, in the event that Employer or its payroll service provider deposits funds erroneously into my account (s), I authorize Employer, either directly or through its payroll service provider, to debit my account for an amount not to exceed the original amount of the erroneous credit.

To the extent permitted by law, I understand that I have the right to refuse consent or revoke authorization of direct deposit at any time without fear of retaliation, and I have the right to receive any payment owed to me by other means. This authorization is to remain in full force and effect until Employer and Bank have received written notice from me of its termination in such time and manner as to afford Employer and Bank reasonable opportunity to act on it.

For a checking account, attach a voided check, not a deposit slip. If you don’t have a check, ask your bank to give you the Routing Number (the nine-digit American Bankers Association (ABA) number that identifies both the Company’s bank and the Federal Reserve Bank) for your account.

Note: If you have a paycard, set it up as a checking account, not a savings account. Contact the paycard issuer for the account number/routing number information.