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EMPLOYEE PAYROLL DEDUCTION AUTORIZATION
Name
Social Security number
Deduction Effective Date
Payroll Deductions:
Background Check
Drug Testing
T-Shirt
Water Bottle
Other
Amount
I agree that my gross pay will be reduced by the amount, or my deduction as checked and indicated above. In the event of a deduction change during the year, my employer is authorized to deduct the new amount from my pay. In the event a new Employee Deduction Authorization Form is not executed on or before the nest year-end, this form shall be deemed to continue in force for next succeeding year.
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