Payroll Deduction Form
Fill out the form below to authorize a payroll deduction from each paycheck to be donated to Box 4
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birthdate
*
-
Month
-
Day
Year
Date
Employee Number
*
Last 4 of SSN
*
Station/Shift
*
Deduction Amount
*
$1
$3
$5
$10
Other
Todays Date
*
-
Month
-
Day
Year
Date
By selecting "Agree" below, I hereby certify that the information provided above is correct and accurate and agree to Box 4 Terms of Service. I authorize Dallas Fire-Rescue payroll to deduct the amount specified above to be donated to Box 4 Fire Buff Association Inc.
Please Select
Agree
Signature
*
SUBMIT
SUBMIT
Should be Empty: