Employee Direct Deposit Enrollment Form
Employee Name
First Name
Last Name
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Bank
Account Number
9-Digit Routing Number
Deposit Type:
Dollars ($)
Percentage (%)
Entire Paycheck
Amount:
Amount:
Type of Account:
Checking
Savings
Other
Attach a voided check for each bank account to which funds should be deposited.
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of
Company Name
is hereby authorized to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.
Employee Signature
Date
-
Month
-
Day
Year
Date
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Submit
Submit
Should be Empty: