Direct Deposit Authorization Form
Store Number
*
Please Select
1335
1336
4260
4270
4271
4272
4279
4281
4282
4287
4290
4291
4292
4295
4352
8093
8495
Office
Email
Date
*
-
Month
-
Day
Year
Date
Team Member's Legal Name
*
Is this the same name that is on the account?
*
Yes
No
Full name on the account
*
Enter your email below. You will be notified when the change has been made.
example@example.com
9 Digit Routing Number
*
Full Account Number
*
Type of Account
*
Checking
Savings
Please make sure to read this before proceeding
*
Make sure the picture of the document is facing the correct direction. Make sure that everything is clear and readable in the picture.
Voided check or letter from your bank's website with routing and account number
*
Browse Files or click here to take a picture
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Cancel
of
Legal Notice:
*
By digitally signing the document below I hereby authorize New River Vally Puizza LLC to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.
Signature
*
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