Electronic Funds Transfer Authorization

I hereby authorize my employer to directly deposit my pay in the bank account(s) listed below in the percentages specified.  (If two accounts are designated, deposits are to be made in whole percentages of pay to total 100%.)  I have attached a voided check or deposit slip for each account specified below.  This authorization is to remain in force until the company has received written authorization from me of its termination or change.

Also, I grant [Your Business] the right to correct any Electronic Funds Transfer resulting from an erroneous overpayment by debiting my account to the extent of such overpayment.

Name: _____________________________________________________________

Address: ___________________________________________________________

Telephone: (           )  ________________

Signature: ____________________________________	    Date: ____________

Company Use Only: Effective Date  _____________________________________
____________________________________________________________________

Account #1      Checking_____________  Savings___________  (Check only one)

Financial Institution: __________________________________________________

Street Address: _____________________________________________________

City, State and Zip Code: _____________________________________________

Telephone: (           )  ________________

Personal Account Number: ____________________________________________

Percent of pay to be deposited into this account: __________________________%

Company Use Only: Bank/ABA Number _________________________________
___________________________________________________________________

Account #2      Checking_____________  Savings___________  (Check only one)

Financial Institution: __________________________________________________

Street Address: _____________________________________________________

City, State and Zip Code: ______________________________________________

Telephone: (           )  ________________

Personal Account Number: ____________________________________________

Percent of pay to be deposited into this account: __________________________%

Company Use Only: Bank/ABA Number ________________________________
___________________________________________________________________