Form 18 Direct Deposit Form

National Cancer Institute
Central IRB Initiative
CIRB Operations Office
c/o: The EMMES Corporation
401 N. Washington St. Suite 700
Rockville, MD 20850
Tel: 1 -888-657-3711 (Toll Free)
Fax: 301-560-6538
E-mail: ncicirbcontact@emmes.com

OMB#: 0925 – xxxx Expiry Date: xx/xx/xxxx
STATEMENT OF CONFIDENTIALITY:
Collection of this information is authorized under 42 USC 285a. Your participation is completely voluntary. You are subject
to no penalty if you choose not to provide all or any part of the requested information. Under the provisions of Section
301d of the Public Health Service Act, no information that could permit identification of a participating individual may be
released. All such information will be kept private under the Privacy Act and will be presented only in statistical or
summary form.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN:
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

Attachment 4:
DIRECT DEPOSIT FORM

-

Expense Reimbursements
Consultant Payments

Employee/Consultant Name
Check one:
Bank Name

___ Checking ___ Savings

Account #
Bank Routing #

__ __ __ __ __ __ __ __ __

In lieu of a live check for payment of expense reimbursements or other amounts due
me, I hereby authorize the EMMES Corporation to deposit remittances to the above
specified Financial Institution and account.
Signature: ________________________________________ Date: ___________

EMMES Approval: _________________________________ Date: ___________