DIRECT DEPOSIT AUTHORIZATION FORM

Direct Deposit Authorization Form

Primary Account Designation

IMPORTANT — Please verify routing and account numbers carefully to ensure proper processing of funds.

Optional Secondary Account

Statement of Agreement for Above Selections

By signing below, I authorize Alliance Medical Staffing Inc., and its agents and financial institutions, to initiate electronic credit entries to the account(s) listed above and, if necessary, debit entries or adjustments for any credits made in error. I represent and warrant that the account(s) identified above are held in my name and that I am an authorized signer on each account. This authorization shall remain in full force and effect until Alliance Medical Staffing Inc. receives written notice from me of its revocation.