Deadline to order Day at the Park T-shirts is June 21. Payroll deduction will be the only form of payment accepted. Please check the boxes and quantities of shirt(s) requested below.  Select from Women's fitted, Unisex or Youth. Indicate payroll deduction date at end of form, add your total amount authorized and check the box to authorize payroll to deduct from your paycheck.  

All shirts are $15.00 each and $5.00 of each shirt goes to Pink at the Park fundraiser for CMBC.

If the due date of the above selected pay date has passed prior to my election/submission of this form, I fully understand that the deduction amount will be made from the next available pay date stated above.  

I fully understand that no refunds or deletions can be made after my authorization has been     submitted via this form.

I understand and agree that I am responsible for satisfying the above amounts. I further understand and agree that deductions will be made after any mandatory taxes as well as for any employer programs in which I have enrolled, for which I am eligible, of to which I have agreed.

I understand and agree that any amount that is due and owing at the time of my termination, regardless of whether my termination was voluntary or not, will be deducted from my last paycheck or any other amounts that may be owed to me. This authorizes TRA Medical Imaging to retain the entire amount of my last paycheck in compliance with the law.