I, Employee's Name hereby authorize PRN Inc. to indicate credit entries and to indicate, if necessary debit and adjustments for any reason entries in error to my account checking or savings.

DEPOSITORY NAME:
BRANCH:
CITY:
STATE:
TRANSIT/ABA#
ACCOUNT #

This authority is to remain in full force and effect until PRN Inc. has received written notification of its termination in such time and in such manner as to afford PRN Inc. reasonable opportunity to act on it.

EMPLOYEE NAME:

SIGNATURE:

DATE: (month/day/year) / /

Please Attach a voided check from checking account selected.
Thank You.

After you've completed this form, please type PRN in this box * to validate this form then click the "Submit" button.

FOR COMPANY USE ONLY

DATE RECEIVED: / /

PROCESSED BY: