Employee Authorization Agreement Direct payments (ACH Debit)

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					         Employee Authorization Agreement
           Direct payments (ACH Debit)

I (we) hereby authorize The Choice Care Card., hereinafter called COMPANY, to
debit entries to my (our) account indicated below in the bank named below,
hereinafter called BANK, to debit the same to such account.


Bank Name: ___________________________________ Branch: ____________

Bank Address: __________________________________

__________________________________

Account holder’s name: ____________________________________

Account Number: _________________________________________

Transit Routing Number (9 digits): ___________________________

Amount to be deducted: $________________


Type of Account (Please check one) Checking      Savings


Company Name: ______________________________________________________
Employee name: ______________________________________________________
Employee’s Social Security Number: _____________________
Signature: _____________________________________ Date: _________________




                                                                           Revised March 30, 2009