Direct Deposit e-form

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) *

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 *

Clear
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Authorization Date *

Month Day Year
Date
Voided Check/Bank Form From Bank

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Authorization For Direct Deposit