FSNB | Direct Deposit Application

DIRECT DEPOSIT OF FUNDS AUTHORIZATION FORM

YOU, AS MY EMPLOYER, ARE HEREBY AUTHORIZED AND INSTRUCTED TO DEDUCT THE AMOUNT SPECIFIED FROM MY WAGES AND FORWARD SAID AMOUNT TO FSNB, N.A. FOR CREDIT TO MY ACCOUNT AS FOLLOWS:

All Salary or Wages

YES NO (specify amount below)

Checking Account #

Specific Amount $

Savings Account #

FSNB ROUTING NUMBER: 103112675

Name

Address

City/State/Zip

Social Security #

Signature (print then sign)

Date

ATTENTION: HUMAN RESOURCES DEPARTMENT

Employer

Address

City/State/Zip

Phone (not required)

Fax