Fillable Authorization Agreement for Automatic Deposits (Philadelphia College of Osteopathic Medicine)

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Authorization Agreement for Automatic Deposits (Philadelphia College of Osteopathic Medicine)

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■ New
■ Change*
■
PCOM
■
GA-PCOM
Payroll Department 215-871-6924
Authorization Agreement for Automatic Deposits
E m p l o yee Info r m a t i o n
I hereby authori z e PCOM to initiate automatic deposits to the accounts listed above and make an
adjustment (debit or credit) if an error has occurred.
This authority is to remain in full force and effect until PCOM has received written notification of
t e r mination in a timely manner to afford PCOM and the bank a reasonable opportunity to process it.
E m p l o yee Signature D a t e
N A M E
SOCIAL SECURITY NUMBER
✆
P H O N E N U M B E R
BANK NAME BRANCH ACCOUNT NUMBER
**FIXED/
AMOUNT
(1) P
R I M A R Y
■ C
H E C K I N G
■ S
AV I N G S
WHITE COPY – PAY R OLL Y E L L O W COPY – HUMAN RESOURCES PINK COPY - EMPLOY E E
(2) Se c o n d a r y
■ C
H E C K I N G
■ S
AV I N G S
ROUTING NUMBER
** Only pertaining to individuals who choose more than one account, fixed amount, will be deposited into secondary account, primary
account will receive the remainder of the deposit.
(3) Se c o n d a r y
■ C
H E C K I N G
■ S
AV I N G S
(4) Se c o n d a r y
■ C
H E C K I N G
■ S
AV I N G S
You may fill out this form online by clicking in the areas to be completed.
In addition to the completed Authorization Agreement for Automatic Deposits Form,
you are REQUIRED to bring in a voided check or
other bank statement/document that shows:
• your name
• your bank account number
• your bank routing number
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Authorization Agreement for Automatic Deposits (Philadelphia College of Osteopathic Medicine)

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Completed 21 July 2020

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