Authorized Payroll Deduction Application

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EMPLOYER
ACCT NO. *	NAME *	AMOUNT *
BADGE NO. (If Applicable)	- - SOC SEC # *
EMAIL *

FREQUENCY:

WEEKLY
EVERY 2 WEEKS
BI-MONTHLY
MONTHLY

This deduction in the amount of $ * shall be made every pay period following the execution of this assignment and shall continue without further authorization by me until such time as this assignment by its terms expires or is revoked by me by notice in writing delivered to the Payroll Department in the plant where I work. I hereby authorize said Corporation to pay the amount of the deductions to the (assignee) Tech Credit Union.

SPLITS

	ACCT#	AMOUNT
PRIME MEMBER SHARE
PRIME MEMBER DRAFT
PRIME MEMBER IRA
NAME
NAME
NAME
NAME
	TOTAL	$

By checking this box I authorize this payroll Deduction

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