Company Name

Employer

METROSCHOOL DISTRICT

Employee ID #*

Employee Title*

First Name*

Last Name*

LAST 4 of Social Security #*

Phone Number*

Address*

I (we) hereby authorize PEOPLE’S CHOICE ASSOCIATION, hereinafter called Company, to initiate debit entries to my (our) Checking Account / Savings Account indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the organization of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Depository Name/Bank Name*

Account Title*

Routing Number*

Account Number*

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Date*

E-Signature*