Employer Payroll Deduction Request Form
If your company or organization has not yet set up payroll deduction with The Scrub Shop, please complete the form below. If you have any additional questions, please feel free to contact us at 864-289-0944 or keely@thescrubshop.com
Billing Type
*
Please Select
Corporate Billing
Payroll Deduction
Full Name
*
First Name
Last Name
Employer/Facility Name
*
Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Department
Job Title
Email
*
Phone Number
*
-
Area Code
Phone Number
Employee Allowance Amount
*
Number of Deductions
*
Would you double verification for your employees?
*
Yes, double verify. The Scrub Shop will require verification at the time of online account setup and also when an order is placed.
No, only require verification when they place an order using payroll deduction.
Other: Please verify in "Additional Comments" section below.
Additional Comments
Submit
Should be Empty: