Employee Direct Deposit Authorization

Name*
First Last
Bank Name*
Routing Number*
Account Number*
Check Image*
Accepted file types: jpg, png, pdf.
Authorization*
- I wish to have my entire paycheck directly deposited into my bank account. I authorize Pediatric People, PLLC to initiate electronic entries and, if necessary, debit entries and adjustments for any credit entries in error to my bank account each pay period. This authority will remain in effect until I notify Pediatric People, PLLC in writing.
Signature*