subject_line
Direct Deposit Submission or Change
First name
*
Last name
*
Email address
*
Effective date
*
🛈
+
Traveler Type:
*
🛈
New
Returning
Current
Bank information
** Please note that we can't do Direct Deposits into Canadian bank accounts at this time.
Type
*
New
Change
Stop
1. Name of Financial Institution
*
Routing number
*
🛈
Account number
*
🛈
Account type
*
Savings
Checking
Full Net
Partial Deposit
🛈
Percentage Deposit
Amount
Amount
Type
New
Change
Stop
2. Name of Financial Institution
Routing number
🛈
Account number
🛈
Account type
Savings
Checking
Full Net
Partial Deposit
🛈
Percentage Deposit
Amount
Percentage
Type
New
Change
Stop
3. Name of Financial Institution
Routing number
🛈
Account number
🛈
Account type
Savings
Checking
Full Net
Partial Deposit
🛈
Percentage Deposit
Amount
Percentage
Authorization
Direct Deposit Verification: Please upload a Voided check or E-Bank verification screenshot ** This is required to ensure accurate processing and added security to our employees
*
Authorization
*
I authorize Emerald Health Services to initiate credit entries to the account indicated above for the purpose of expense and/or payroll. I also authorize Emerald Health Services to initiate, if necessary, debit entries and adjustments for any credit entries made in error.
Signature
*
clear