Authorization Agreement for Direct Deposits

Name*

First Last

Social/EIN*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

New Authorization or Update Existing*

Bank Name*

Branch

Branch Location*

City State

Routing Number*

Account Number*

How much should be deposited?*

Dollar Amount
Percent Amount
Entire Paycheck

Dollar Amount to Deposit*

Percent Amount to Deposit*

Account Type*

Checking Account
Savings Account

Voided Check

Accepted file types: jpg, png, gif, Max. file size: 200 MB.

Upload an image of a voided check for the bank account to which funds should be deposited (if necessary). [.jpg, .png, .gif]

Consent*

I agree to the terms below.

I hereby authorize PRECISION HEALTHCARE STAFFING, LLC, hereinafter called COMPANY, to initiate credit entries and/or correction entries to my checking or savings account as specified above.

This authorization is to remain in full force until COMPANY has received written notification from me of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY reasonable opportunity to act upon it.

Employee Signature*