To take advantage of direct deposit of your Burnett Staffing Specialists or Choice Staffing 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.

Please print clearly

Sign-Up Form for Direct Deposit

1. To sign up for direct deposit, the payee should read instructions carefully, then hand-deliver, mail or fax this form to your service center.
2. You can deposit in a maximum of two accounts.
3. Complete the form by stating the amount to be deposited into one account and the balance to deposit into the second account if depositing into more than one account.
4. Please keep Burnett/Choice informed of any address changes in order to receive important payroll information and other benefits sent by mail.
5. Most information to complete your form is located on the check issued by the bank.
6. Be sure your name is written exactly as it appears on the check. Be sure current address/telephone is on check.
7. Routing number and account number is found at the bottom of the check (attach to check to completed form)
8. Joint account holders must both sign the form.
9. To cancel, please fax a note signed by the account holder/payee to 713-975-7431.
10. Changing financial institutions, please complete a new form and send to your service center. All processed funds will be deposited into the old account until the new form is received in the Pay/Bill Department.

Payee: _____________________________________________________________________________________

Address: ___________________________________________________________________________________

City: __________________________ , TX Zip: ____________ Phone: #:_________________________ (Day)

Social Security #: ______ - ____ - ________ Employee ID: ___________________________ Office: __________

Bank or Savings Institution Name: ________________________________________________________________

Type of Account: _____Checking _____ Saving _____ Other (explain)___________________________________

Account No. ____________________________________ Rte. No. _____________________________________

Amount to Deposit if not full check: $ ______________.____

Bank or Savings Institution Name: ________________________________________________________________

Type of Account: _____Checking _____ Saving _____ Other (explain)_________________________________

Account No. ____________________________________ Rte. No. _____________________________________

Amount to Deposit if not full check: $ ______________.____ Deposit my Expense Check, also: [ ] Yes [ ] No

I (we) hereby authorize Burnett/Choice to initiate credit entries from payroll processing into my account. In the event there is a processing problem, Burnett/Choice has my (our) approval to debit for that error only. This agreement is to remain in full force until Burnett/Choice has received written notification from the employee of it's termination in such time and in some manner as to afford Burnett/Choice a reasonable opportunity to act on it.

I (we) understand that the deposit of my funds may be delayed beyond two days upon occasion. Burnett/Choice is not liable and will not pay for returned check charges and that I am responsible for checking my account for deposited funds prior to writing checks against deposits to be made by Burnett/Choice.

I (we) authorize and understand any expense check to be direct deposited in the account.

Signer #1: _____________________________________________________ Date: ______________________

Signer #2: _____________________________________________________ Date: ______________________

Employee: _____________________________________________________ Date: ______________________

Attach Check or Deposit Form Here

Burnett/Choice use only: Fax to Pay/Bill By: ____________________________ Date: ______________________