E:\FORMS FOR PAYROLL\AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS - 2012.DOC
Revision Date: June 2012 f
This form is required to ADD or CHANGE an existing direct deposit and must be received by the payroll Department
before payment can be processed, this authorization must be signed by the employee to be valid.
First Name: ____________________________ Last Name: ____________________________
Student Number: _______________________
Address: _________________________________________________________________________________
City: ______________________ Province: _______________ Postal Code: _______________
Attach a void cheque or fill out the following information (must be completed by your financial
institution):
Bank Name: ______________________________________________________________________________
Bank Address: ____________________________________________________________________________
Bank Number: ____________________ Bank Transit Number: ___________________
Bank Account Number: _______________________________________
Branch Verification Signature: _________________________________
Please note that all banking information will be passed on to Accounts Payable to set up direct deposit for
reimbursement of expenses. If you would like to have these funds deposited to a different bank account other than
the one that has been specified for Payroll, please contact the Accounts Payable Department at ext 2123.
I HEREBY AUTHORIZE THE UNIVERSITY OF WINDSOR TO DEPOSIT MY PAYROLL AND ACCOUNTS
PAYABLE PAYMENTS DIRECTLY TO THE BANK ACCOUNT PROVIDED ABOVE.
Please complete the following: New Setup Change of Account
Employee’s Signature: _____________________________ Date: ____________________
Finance Department
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS
Submit Form To: Payroll Department. Any inquiries should be directed to this department at (519)
253-3000 ext. 2135
mm/dd/yyyy
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