DIRECT DEPOSIT FOR TRAVEL

I hereby authorize the Department of Energy to send my travel payments directly to the account indicated below:

_____________________________ ______________________________

Bank’s Routing Number Account Number

Is this a Checking or Savings Account ________C ________S

Are you a current DOE employee? ________Yes _______ No

If yes, is this the account used for your net salary deposit?

_______ Yes _______ No

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Current Home Address: _______________________________________________

City: ___________________________ State __________ Zip ____________

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Social Security #_______________________

Work Phone Number _____________________Fax Number _______________

Email Address for payment notification _______________________________

Print Name: __________________________________________________________

Signature: ___________________________________________________________

Please FAX the completed form to 301-903-5240 or mail to Travel Team, CF-11 Room C-278, GTN