WWW.ASA.EDU
DOWNTOWN BROOKLYN
151 Lawrence Street
Brooklyn, NY 11201
Tel.: 718 - 522-9073
NORTH MIAMI BEACH
3909 N.E. 163rd Street
North Miami Beach, FL 33160
Tel.: 786-279-1740
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel.: 212-672-6450
Signature of the Employee
Date (MM/DD/YYYY)
Signature of the HR Representative
Date (MM/DD/YYYY)
PAY CARD DEPOSIT AUTHORIZATION FORM
To be able to receive your pay as Pay Card, you must complete the following:
Complete the employee section of this form.
Return (e-mail) completed form to the Human Resources office.
I hereby authorize ASA College each pay day to deposit: $ ________ Entire Net Amount
of my paycheck as a Pay Card. In the event of the Pay Card to be credited with an erroneous payment, I
authorize the reversal of the erroneous payment, or the recovery of the erroneous payment from any
funds remaining in my future compensation.
TO BE COMPLETED BY EMPLOYEE:
TO BE COMPLETED BY HR REPRESENTATIVE:
New Enrollment
Modify Enrollment
Cancel Enrollment
Name of the Employee:
Last: ______________________________________ First: ___________________________ Middle:_________________
Address:
______________________________________ City: _____________________ State:_______ Zip:_________________
Cell phone: _____________________ Home phone: _______________________ Work Phone: _____________________
Personal e-mail: ____________________________________ Work e-mail: ______________________________________
Date of Birth: __________________ Social Security #: _____________________
Department/Oce: _________________________________________________________________________________
Job Title _______________________________________________________ Employee ID#: _______________________
Acct.Type:
Pay Card _____________________________________
Account Number
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