Direct Deposit Enrollment/Change Form
Pediatric Advanced Therapy
Employee Name
*
First Name
Last Name
Complete to Enroll/Change Bank Accounts
Acct Type
Bank Acct Number
Routing Number
Bank Name
I Wish to Deposit
Account 1
Checking
Savings
100% of Net
Specific Dollar Amount
Remainder of Pay
Other (describe)
Account 2
Checking
Savings
100% of Net
Specific Dollar Amount
Remainder of Pay
Other (describe)
Description of Other (if necessary)
Copy of Voided Check/Deposit Slip/Bank letter or Other Bank Documentation
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Date
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