To take advantage of direct deposit of your Burnett Staffing Specialists or Choice Staffing Services paycheck into your checking account, please fill out the form below and attach a voided check in the space provided. To accurately enter your information into the banking system, please make sure you complete all the spaces and attach your check. For employees who have savings only, please attach a deposit slip.

All Burnett / Choice employee earnings are made by either direct deposit or applied to a paycard.
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AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (ACH CREDITS)

The Burnett Companies Consolidated, Inc. Company ID #76-0080808

I (we) hereby authorize The Burnett Companies Consolidated, Inc., hereinafter called COMPANY, to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my (our) account. This agreement is to remain in full force until COMPANY has received written notification from me of its termination in such time and in some manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Kind of Account: (Please select one): [ ] Checking  [ ] Savings Amount to Deposit: $_______________________

Bank Name: ___________________________________________ Bank Telephone Number: (_____)_______________

Bank Deposit Routing Number: _____________________________ Acct Number: _____________________________

Employee Name: __________________________________________________________________________________

Social Security Number: ___________ -_________-____________ Driver’s License # ___________________________

Co-Signer Name: __________________________________________________________________________________

Social Security Number: ___________ -_________-____________ Driver’s License # ___________________________

Deposit my Expense Check, also: [ ] Yes [ ] No I understand that the deposit of my funds may be delayed beyond
two days upon occasion. I understand that Burnett/Choice will not pay for returned check charges and that I am responsible
for checking my account for deposited funds prior to writing checks against that amount.

Employee Signature: _________________________________________________________ Date: ____________

Co Signer’s Signature: ________________________________________________________ Date: ____________

******Please attach check here (check must be attached for checking account or deposit slip for savings)