WSDOT MF Payroll Deduction Authorization Form

AUTHORIZATION FOR PAYROLL DEDUCTION
I hereby authorize a payroll deduction to be made from my salary as specified below
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
I do not wish to receive Newsletters and updates regarding the Memorial Foundation
Deduction Amount Per Pay Period*
Agency Number*
WSDOT=405
Employee ID#*
Signature*

Clear
Date *
NOTE: EFFECTIVE START DATE WILL BE NEXT PAY CYCLE AFTER PAYROLL OFFICE RECEIPT OF THIS FORM
Choose One Item (Good while supplies last, subject to availability)*

MLXL2XL3XL
Hoody:

CamoGreenOrange
Full Zip Hoody:

Black w/ Camo Sleeves
1/4 Zip:

Olive w/ Camo Sleeves
Fleece Vest:

MaleFemale
Puffy Vest:

MaleFemale
Polo:

Dark Green
No-Iron Gray Dress Shirt:

MaleFemale
T-Shirt:

"Learn the Signs"
Cap:

Real TreeGreenOrangeBlackGray/Lime Green
Blanket:

WhiteBlackGrayBuffalo Plaid
Misc.:

Pin (Mem. Foundation and Ribbon)History BookTravel Cup
Notes:
Should be Empty:

I hereby authorize a payroll deduction to be made from my salary as specified below