Direct Deposit Authorization Agreement Form I hereby authorize

Direct Deposit Authorization Agreement Form
I hereby authorize Hannibal-LaGrange University to electronically deposit my monthly
payroll check into the bank account(s) listed below.
Date: ________________________
Your Name: _____________________________________________
Bank Information
Bank Name _______________________________________________
Address __________________________________________________
City, State, Zip code ________________________________________
Account Number ___________________________________________
Bank Transit Number _______________________________________
Account Type
Checking
Savings
Amount to be Deposited _____________________________________
(leave blank if entire amount will be deposited to this account)
Bank Name _______________________________________________
Address __________________________________________________
City, State, Zip code ________________________________________
Account Number ___________________________________________
Bank Transit Number _______________________________________
Account Type
Checking
Savings
Amount to be Deposited _____________________________________
(leave blank if entire amount will be deposited to this account)
Bank Name _______________________________________________
Address __________________________________________________
City, State, Zip code ________________________________________
Account Number ___________________________________________
Bank Transit Number _______________________________________
Account Type
Checking
Savings
Amount to be Deposited _____________________________________
(leave blank if entire amount will be deposited to this account)
Signature _________________________________________________
Note: Be sure to attach a cancelled check, photocopy of a check, or savings account
statement.