Direct Deposit Authorization Form
Employee Information
Employee Name
*
First Name
Last Name
Employee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Email Address
*
example@example.com
Bank Information
Bank Name
*
Account Type (Select One)
*
Checking
Savings
Routing Number
*
Account Number
*
Please attach a voided copy of a deposit slip, check, or bank verification of account to this form.
*
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Authorization
I hereby authorize Mapleton City to initiative direct deposits to my account at the financial institution indicated above. I also authorize the financial institution to accept and credit any deposits made by Mapleton City to my account. This authorization will remain in effect until I provide written notification to Mapleton City to terminate it.
*
Confirmed
Employee Signature
*
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