Payroll Deduction Authorization Form
First Name
*
Last Name
*
Supervisor's Name
*
Payroll Date that applies
*
Select which Deduction you are requesting
*
Y Shirt
Lifeguard Certificate
Lifeguard Suit
Miscellaneous
Deduction Amount
*
GL Account #
*
Total Deduction Amount
*
How would you like the total amount deducted?
*
One payment
Two equal payments
Three equal payments
Comments or special instructions:
I authorize the ORYMCA to deduct the amount indicated above from my paycheck.
*
Submit
Should be Empty: