Payroll Direct Deposit

I (we) hereby authorize Professional Nursing Service, a division of Bonneville Health Recruiters, hereinafter called COMPANY, to initiate credit entries to my (our) Checking account     Savings account (select one) indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the same to such account. Include a voided check for deposits to a checking account with this authorization.

Depository Name:
Branch:
City:
State:        ZIP:
Routing #:
Account #:
This authorization is to stay in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
First Name:        Middle Initial:
Last Name:
Social Security #:
  The information I have given is true and accurate.
Date:

First Name:        Middle Initial:
Last Name:
Social Security #:
  The information I have given is true and accurate.
Date:
NOTE: All written credit authorizations MUST provide that the receiver may revoke, the authorization only by notifying the originator in the manner specified in the authorization.