AUTHORIZATION FOR DIRECT DEPOSIT AND ELECTRONIC PAY STATEMENTS FOR EMPLOYEE PAYROLL A. T. STILL UNIVERSITY OF HEALTH SCIENCES PLEASE RETURN FORM TO ATSU HUMAN RESOURCE OFFICE NAME ______________________________________ (print only)

Activation Date___________________________

I (we) hereby authorize ATSU to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my (our) bank account indicated below and the bank named below to credit and/or debit the same to such account. FINANCIAL INSTITUTION INFORMATION: #1Account NAME OF BANK ___________________________ BRANCH ___________________________ CITY ______________________________________ STATE ________ ZIP __________________ ROUTING NUMBER OF BANKING INSTITUTION ____________________________(9 digits) ACCOUNT NUMBER TO BE USED _________________________________________________ TYPE OF ACCT:_____CHECKING _____ SAVINGS AMOUNT TO BE DEPOSITED IN THIS ACCOUNT ______________________ (100% or $$amount) #2Account NAME OF BANK ___________________________ BRANCH ___________________________ CITY ______________________________________ STATE ________ ZIP __________________ ROUTING NUMBER OF BANKING INSTITUTION ____________________________(9 digits) ACCOUNT NUMBER TO BE USED _________________________________________________ TYPE OF ACCT:_____CHECKING _____ SAVINGS AMOUNT TO BE DEPOSITED IN THIS ACCOUNT ______________________ (100% or $$amount) This authority is to remain in full force and effect until the ATSU Human Resources Office has received written notification from me (or either of us) of its termination in such time and in such manner as to afford ATSU and the financial institution a reasonable opportunity to act on it. I (We) will be held accountable for any bank fee charges resulting from inaccurate transfer information provided. My (Our) signature(s) below indicates agreement with the above terms and conditions for automatic deposits and electronic pay statements. NAME(S) ON ACCOUNT ______________________________ ______________________________ SIGNATURE 1 _________________________________ SOC. SEC. # ________________________ SIGNATURE 2 _________________________________ SOC. SEC. # ________________________ DATE SIGNED _____________ We take our responsibility to protect the privacy and confidentiality of your information seriously. ATSU maintains safeguards to store and secure information about you from unauthorized access, alteration, and destruction .

PLEASE ATTACH A BLANK VOIDED CHECK OR DOCUMENTATION FROM YOUR BANK WITH ACCOUNT INFORMATION.