Direct Deposit Authorization Form

Please print and complete ALL the information below.

Name *

Employee Name *

Date of Birth *

Address, City *

State, Zip *

Social Security # *

Position/Title *

Date of Hire *

Pay Rate $ *

Name of Bank *

Account # *

9-Digit Routing # *

Amount *
  $
  %
  Entire Paycheck

Type of Account *

Checking

Savings

Gender *

Male

Female

Employment Status *

Active

Terminated

Tax Status *

W2

1099

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

I authorized Ronara Staffing Solutions to direct deposit my pay in to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.

Employee Signature *

Date *