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Direct Deposit Authorization Form
Fill out and submit this form if you believe you are owed a retro payment from GVI.
10
Questions
START
1
Name
*
This field is required.
First Name
Last Name
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2
Social Security Number
*
This field is required.
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3
What is (or was) your employee number?
*
This field is required.
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4
Primary Phone Number
*
This field is required.
Please enter a valid phone number.
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5
Alternate Phone Number
*
This field is required.
Please enter a valid phone number.
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6
Banking Institution
*
This field is required.
Name of your bank
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7
Please indicate type of account:
*
This field is required.
Savings
Checking
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8
Routing Number
*
This field is required.
9 digits
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9
Account Number
*
This field is required.
8-15 digits
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10
Signature
Clear
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11
Sign the document using the following format: "/s/ first name & last name"
Typing your name below is the equivalent of signing this document
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12
Name
First Name
Last Name
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