Direct Deposit Authorization

Name*

First Last

NOTES

done

Last four of Social Security Number:*

Phone*

Email:*

Your check stubs will be sent to the e-mails every Friday.

What job site are you currently assigned?*

Authorization Agreement

I hereby authorize Provide Staff to initiate automatic deposits to my account at the financial institution named below. I also authorize Provide Staff to make withdrawals from this account in the event that a credit entry is made in error.

Further, I agree not to hold Provide Staff responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.

This agreement will remain in effect until Provide Staff receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.

Account Information

PLEASE verify your account and routing numbers. $35.00 ACH FEE FOR RETURNED FUNDS FOR INCORRECT BANKING INFORMATION.

Name of Financial Institution*

Routing Number*

Account Number*

Type of Account*

Checking
Savings

Signature

Authorized Signature (Primary)*

Authorized Signature (Joint)

Date*

Time*

: HH

MM

Comments

This field is for validation purposes and should be left unchanged.