Direct Deposit Agreement

Authorization Agreement

I hereby authorize Assist Medical Staffing to initiate automatic deposits to my account at the financial institution named below. I also authorize Assist Medical Staffing to make withdrawals from this account in the event that a credit entry is made in error.

Further, I agree not to hold Assist Medical Staffing responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.

This agreement will remain in effect until Assist Medical Staffing receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.

Account Information


Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Direct Deposit Agreement
lock iconUnique Document ID: dceef0549f00c8a4bfdb3fc0a4ef639ccd5e49c1
Timestamp Audit
January 24, 2023 4:46 pm EDTDirect Deposit Agreement Uploaded by Assist Medical Staffing - IP
February 6, 2023 1:15 pm EDT Document owner has handed over this document to 2023-02-06 13:15:51 -