DIRECT DEPOSIT AUTHORIZATION
Employee Name: ______________________________ Date: _________________________
By signing this agreement, you authorize Pavlov Media to initiate credits and make adjustments, if necessary, for any
entry made in error. Any changes must be made in writing on the Direct Deposit Authorization Form.
New Payroll Deposit Change Deposit Information
Direct Deposit #1 Financial Institution Name: _________________________________
Net Pay Routing & Transit Number: _________________________________
Or
$________ Account Number: _________________________________________
Checking Savings
Direct Deposit #2 Financial Institution Name: _________________________________
Net Pay Routing & Transit Number: _________________________________
Or
Account Number: _________________________________________
$________
Checking Savings
Direct Deposit #3 Financial Institution Name: _________________________________
Net Pay Routing & Transit Number: _________________________________
Or
$________ Account Number: _________________________________________
Checking Savings
It is the employee’s responsibility to verify the routing/transit number and account number. Direct Deposit requires a
10 day pre-note. The pre-note process will be activated with your first payroll.
This authorization will remain in effect until I give written notice or revoke it upon my termination of employment with
Pavlov Media, Inc.
Employee Signature________________________________ Date ___________________
You must attach a voided check, a copy of a voided check, or a financial institution specification sheet for savings
accounts.
I DO NOT WISH TO HAVE DIRECT DEPOSIT _________________________________ ___________
Employee Signature Date
