BALLAD HEALTH AUXILIARY FUNDRAISING SALE PAYROLL DEDUCTION FORM

BALLAD HEALTH AUXILIARY FUNDRAISING SALE PAYROLL DEDUCTION FORM
EMPLOYEE NUMBER
EMPLOYEE NAME Please print then sign
Mailing Address Street or PO Box
City, State
Zip Code
TELEPHONE NUMBER (HOME OR CELL)
PERSONAL E MAIL ADDRESS
example@example.com
Ballad Health Facility
TOTAL DEDUCTION AMOUNT
TOTAL PURCHASE
NOTE: For purchases less than $50, payroll deductions are limited to 1 pay period. Total payroll deductions cannot exceed $400. The balance of purchase may be paid with cash, check, or credit card depending on what payment methods the vendor is able to accept.

I authorize deductions from my payroll check. If my employment terminates for any reason from Ballad Health, I authorize any remaining balance to be deducted from my final payroll check. I further understand and agree that if my final payroll check is not sufficient to satisfy any remaining balance due for this purchase, I will remit payment of any remaining balance (after deduction of the final payroll check) within five (5) days of my last date of employment at Ballad Health. If terms of this agreement are not met the balance could be turned over to a third party for collection in which I am responsible for all collection/legal fees.
DATE

MonthDayYear
Date
TEAM MEMBER SIGNATURE
Signature

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