Partners Helping Partners - Payroll Deduction Authorization

Partner #: *
Full Legal Name: Full Legal Name: * Title First Middle Last Suffix
Payroll Deduction (amount must be between $1 - $10 per week):
PHP Fund (Weekly): *
Must be a number less than or equal to 10.
PHP Fund (one time donation lump sum): *
In the event of a deduction change during the year, a new authorization must be completed. This authorization shall be deemed to continue in force until a change form is completed or Partner cancels deduction.
Employee Signature: *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date: Date: * / MM / DD YYYY
* Submitted forms are sent to Payroll Department at PayrollDepartment@mooreselectric.com.
Type the letters you see in the image below.