Direct Deposit Authorization
Letter and voided check, letter size
11/04/2026
Bloomhaven Wellness Retreats LLC
5373 W Alabama St, Suite 204
Houston, TX 77056
Re: Direct Deposit
Please present this letter to your employer to set up your direct deposit.
CONTACT INFORMATION
Name
Bloomhaven Wellness Retreats LLC
Address
5373 W Alabama St, Suite 204, Houston, TX 77056
Phone Number
713-874-9669
Email Address
Care@bloomhavenwellnessclinic.com
BANKING INFORMATION
Routing Number
111-900-785
Account Number
Business Checking - 037-813-4897
Deposit Amount
100%
FINANCIAL INSTITUTION
Name
Regions Bank
Address
1900 Fifth Avenue North, Birmingham, AL 35203
Phone Number
1-800-734-4667
AUTHORIZATION
I authorize my employer to initiate the direct deposit of my paycheck into the account listed above. I understand my typed name will appear on the signature line and have the same legal effect as a hand written signature. A signed direct deposit will not be initiated until I have submitted this form to my employer and it has been fully processed.
Jasmine Randolph
SIGNATURE
11/04/2026
DATE
VOIDED CHECK
Bloomhaven Wellness Retreats LLC
5373 W Alabama St, Suite 204
Houston, TX 77056
001
11/04/2026
NON NEGOTIABLE
PAY TO THE ORDER OF
$
DOLLARS
MEMO
Voided specimen for direct deposit setup
VOID
REGIONS BANK
:111900785: 0378134897*
AUTHORIZED SIGNATURE
Regions Bank · 07/26
Bloomhaven Wellness Retreats LLC