Direct Deposit Authorization Form

Authorization for Direct Deposit

For electronic fund transfers (EFT) from the Institute for Spirituality and Health at the Texas Medical Center, complete and sign this form.
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AUTHORIZATION FOR DIRECT DEPOSIT STATEMENT: I hereby authorize the Institute for Spirituality and Health at the Texas Medical Center to initiate automatic deposits to my account at the financial institution named below. I also authorize the Institute for Spirituality and Health at the Texas Medical Center to make withdrawals from this account in the event a credit entry is made in error.

I agree not to hold the Institute for Spirituality and Health at the Texas Medical Center 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 the Institute for Spirituality and Health at the Texas Medical Center receives a written notice of cancellation from me or my financial institution, or until I submit a new/updated direct deposit form.
I agree to the above Authorization for Direct Deposit Statement*

Yes, I agree
Account Information

Personal Banking Information*

	Full Name on Account	Bank Name	Account Number	Routing Number
Main Account

Under penalties of perjury, I declare that I have examined this Authorization for Direct Deposit Form, and to the best of my knowledge and belief, it is true, correct, and complete. I understand this authorization is not valid unless I sign and date below:
Electronic Signature Verifying Account Information and Authorization*

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Full Name: *

First NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Today's Date:*

MonthDayYear
Date
Which of the Institute's programs is your work associated with*
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Authorization for Direct Deposit