I hereby authorize Palmer College of Chiropractic to direct deposit my funds into the account identified below. I will provide at least 30 days written notification to the Palmer Business Office in order to initiate, cancel or change this service for student refunds.
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* First name:
* Last name:
* Bank Name:
Bank Routing Number:
Bank Account Number:
I am submitting this form which serves as my signature to Palmer College of Chiropractic.
Signature on this form acknowledges that Palmer may initiate a reversing entry to correct an erroneous entry previously initiated by Palmer.