Electronic Payment Authorization Form

* = Required Information

Application Checklist

I hereby authorize Elohim Medical Staffing Agency, Inc. to initiate deposits for payroll or to initiate withdrawals for self cancellation or no show fees as payment of services to the account and the financial institution named below. I also authorize a reversal a reversal for credit/debit errors.

Checking Account

Savings Account

A $30.00 returned check fee will be assessed on any payments returned due to insufficient funds.

To the best of my knowledge, information provided on this agreement is true and accurate and I have the authority to bind the above actions on this account.

This authorization will remain in full force unless cancelled by me in writing.

Applicant Name*

Date *

A. Routing Number

B. Account Number

C. Financial Institution Name: *

D. Address *