Payroll Enrollment Form
Your Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Operating as *
Pay to Name *
Your answer
Pay to Address *
Please enter the address associated with the Pay To name as it is registered to your bank.
Your answer
Tax ID *
Enter your EIN or SSN
Your answer
Bank Name *
Your answer
Bank Routing Number *
Your answer
Confirm Routing Number *
Your answer
Bank Account Number *
Your answer
Confirm Account Number *
Your answer
By checking this box, I am confirming that I have entered the correct business or individual entity information - both Tax ID (SSN/EIN) and banking information. I also agree to allow Empower U. and it's program affiliates to deposit funds owed to me for service delivery in the account that I have identified. I also hereby agree to send a voided check to Empower U. prior to payroll being processed. *
Required
Electronically Signed *
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