Authorization For Direct Deposit
This authorizes UNITED MEDICAL STAFFING, INC. to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to my (our) account(s) indicated below and to other accounts I (we) identify in the future (the account;). This authorizes the financial institution holding the account to post all such entries.
Bank Account Type (choose one)
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Checking
Savings
Name of Bank
*
Bank Account #
*
VERIFY IF CORRECT
Re-enter Bank Account #
*
VERIFY IF CORRECT
Bank Routing #
*
VERIFY IF CORRECT
Re-Enter Routing #
*
VERIFY IF CORRECT
This authorization will be in effect until UNITED MEDICAL STAFFING,INC. receives a written termination notice from myself and has a reasonable opportunity to act on it.
Authorization Signature
*
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Authorization Date
*
-
Month
-
Day
Year
Date
Voided Check/Bank Form From Bank
Browse Files
Required for Direct Deposit
Cancel
of
Save
Submit to Payroll/Continue
Should be Empty: