North Georgia Credit Union

EMPLOYER PAYROLL DEDUCTION AUTHORIZATION

Membership Information


Member	Member Account #

Employer	SSN/TIN

Home Phone #	Payroll #

Work Phone #	E-Mail Address

Initial Authorization Change in Authorization

I hereby authorize my Employer to deduct from my salary the amounts set forth below and to deposit these funds at the Credit Union for each payroll period following receipt of this Authorization until further notice from me. If this is a change in a previous Authorization, I instruct my Employer to cancel my previous Authorization and to follow this Authorization. If I fail to cancel this Authorization upon filing for bankruptcy, my Employer and the Credit Union are directed to make and apply deductions in accordance with this Authorization.

Deposit Account	Net Check	Payroll Period	Weekly
	$		Biweekly
			Monthly
			Semi-Monhly
Credit Union R/T #

By checking this box and submitting this application electronically, I agree to the same terms that apply to a signed application.

X______________________________	X______________________________
Signature	Effective Date

CREDIT UNION DIRECT DEPOSIT AUTHRIZATION

By signing or checking above, I authorize the Credit Union to apply my payroll deduction for each pay period as follows:
Share Draft/Checking		$
Share/Savings		$
Money Market		$
Loan #		$
Loan #		$
IRA		$
Other		$
Other		$
	TOTAL	$

Once your application is completed, press the SUBMIT button and send it to the credit union electronically.
If you do not wish to submit this form electronically, you can print, sign and return it to the credit union.

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