PMLA - Direct Deposit Form

School Name
Authorization for Direct Deposit
Employee Information
Employee Name

First NameLast Name
Employee Email*
example@example.com
Declaration
I hereby authorize Pico Mesivta Los Angeles to deposit my pay automatically to the account(s) indicated below and, if necessary, to adjust or reverse a deposit for any payroll entry made to my account in error. This authorization will remain in effect until I cancel it in writing and in such time as to afford Chofetz Chaim Los Angeles a reasonable opportunity to act on it.

Furthermore, by providing authorization for direct deposit, I understand that the school is not committing itself or implying that payroll will be issued via direct deposit at all times. The school will keep this authorization on file, to be used when possible.
Account Information
Name on Bank Account*
Bank Account Number*
Bank Routing Number*
Account Type*

CheckingSavings
Please attach a voided check for the bank account to which funds should be deposited.

Browse Files

Cancelof
Employee Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Authorization for Direct Deposit