PAYROLL ENROLLMENT FORM

By completing this form, you consent for [company name] to deposit your
salary after essential deductions, directly into your bank account on a /monthly
basis.
This form is not valid without the signature of the accountholder.

Employee Section

First Name Middle Name Last Name

Address City State

Phone Date (MM/DD/YY)

Status Signature

Banking Information

Account Number: ___________________________

Account Name : ______________________________________

Bank:
__________________________________________________________________________________________
 Employer Section

Hire Date: _______________________________________

Employment Type: _____________________________(Full Time/Contract/Adhoc)

Annual Salary(N):_______________________________

Monthly Pay(N)__________________________________

Other Financial Benefits(N)_______________________________________________________

Deductions: (State what and amount deducted)

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

Authorized Name Signature Date