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Hello , Thank you for submitting your bank information, we will be enrolling you in our US Bank EFT system.

Name of Facility:

Name of Person Authorizing: , Email : , Phone Number:

Bank Name:

Bank APA Routing Number:

Bank Account Number:

Bank Account Type:

You have provided validation via an uploaded deposit slip or voided check as attached here :

I, the undersigned, represent that I am duly authorized to represent and that I agree the information provided is accurate and complete.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

June 3, 2022 2:36 pm PDT

{{gravity-field-id-1}} - Bank EFT request Uploaded by NV Nurse Apprentice Program Manager - naprequests@nrhp.org IP 134.197.230.125

June 15, 2022 9:31 am PDT

Ann Murdoch - ann@nrhp.org added by Todd Radtke - todd@nrhp.org as a CC'd Recipient Ip: 134.197.230.99

June 15, 2022 9:47 am PDT

Ann Murdoch - ann@nrhp.org added by Todd Radtke - todd@nrhp.org as a CC'd Recipient Ip: 134.197.230.99

June 15, 2022 10:07 am PDT

Ann Murdoch - ann@nrhp.org added by Todd Radtke - todd@nrhp.org as a CC'd Recipient Ip: 134.197.230.99

June 15, 2022 10:58 am PDT

Ann Murdoch - ann@nrhp.org added by Todd Radtke - todd@nrhp.org as a CC'd Recipient Ip: 134.197.230.99

March 1, 2023 11:28 am PDT

Ann Murdoch - ann@nrhp.org added by NV Nurse Apprentice Program Manager - naprequests@nrhp.org as a CC'd Recipient Ip: 134.197.230.125

January 23, 2024 11:22 am PDT

Ann Murdoch - ann@nrhp.org added by NV Nurse Apprentice Program Manager - naprequests@nrhp.org as a CC'd Recipient Ip: 134.197.230.125

February 28, 2024 4:56 pm PDT

Ann Murdoch - ann@nrhp.org added by NV Nurse Apprentice Program Manager - naprequests@nrhp.org as a CC'd Recipient Ip: 134.197.230.125

April 16, 2024 2:54 pm PDT

Ann Murdoch - ann@nrhp.org added by NV Nurse Apprentice Program Manager - naprequests@nrhp.org as a CC'd Recipient Ip: 134.197.230.125