DIRECT DEPOSIT AUTHORIZATION

Name:

I.D.#

S.S.#

Bank Name and Branch:

Account Number:

Check appropriate box:

(  )        Direct deposit.

            The undersigned hereby requests and authorizes the entire amount of my paycheck

each pay period to be deposited directly into the bank account named above.

(  )        Direct payroll deduction deposit.

            The undersigned hereby requests and authorizes the sum of    dollars ($                       )

be deducted from my paycheck each pay period and to be deposited directly

into the bank account named above.

(  )        I would like to cancel my deposit authorization.

            The undersigned hereby cancels the authorization for direct deposit or payroll deduction

deposited previously submitted.

Employee Signature                                                                                  Date

Please attach a copy of deposit slip