DIRECT DEPOSIT ELECTION FORM
Name ____________________________________ SS#
or TIN ______________________
Company _________________________________ Phone
# ________________________
E-mail Address ________________________________________________________________
You
must include your e-mail address, if you desire a remittance/confirmation of
payment.
New
Authorization Change Cancellation
Bank Name ____________________________________________________________________
Routing Number _________________________________________________________________
Account Number ________________________________________________________________
Checking
Savings
You must attach a voided check or deposit
slip.
Effective Date __________________________________________________________________
If you want to start this service immediately, please
use today’s date. Allow a
minimum of four weeks for new automatic deposits to start for the bank to
verify your account.
I hereby authorize the National Collegiate Athletic Association to
initiate credit entries to the account in the bank named above and to debit
entries made in error. I authorize
the bank to accept and to credit or debit the amount of such entries to this
account.
Authorized Signature _____________________________________ Date ________________