National Park Community College
Authorization Agreement for Direct Deposits
I, _______________________________ do hereby authorize the above named company, hereinafter referred to
(Print Name)
as the Originator, to initiate credit entries to the account indicated below, and to initiate corrective reversal
entries (debits) to the account indicated below in the event any credit entries are originated in error.
Name on the Account
Name of Depository
Financial Institution
Location of Depository Financial Institution:
City: State Zip Phone
Routing Number ___ ___ ___ ___ ___ ___ ___ ___ ___ (nine digits on left side of check)
Account Number (middle number, before check #)
Checking _______% of Net Pay or Set Dollar Amount _________________________________
Savings _______% of Net Pay or Set Dollar Amount ___________________________________
This authority is to remain in effect until the Originator has received my/our written notification of its
termination in such time and in such manner as to afford the Originator a reasonable opportunity to act upon it.
NPCC ID
SSN
Signed
Date
AFFIX VOIDED CHECK OR BANK ORIGINATED INFORMATION BELOW
Deposit Slips are not acceptable.
(Return Completed Authorization to the Payroll Office.)
