PAYROLL AUTHORIZATION

I hereby authorize my employer to deduct from my paycheck my contribution for the premium associated with the following coverage’s selected:

 	Medical	Employee	Dependent                     	

Long Term Disability

Employee J.D. Number

 	Dental	Employee	Dependent                                    401-K Contribution
 	Life 	Employee	Dependent                  	Credit Union	Effective Date
 	Other  	

I also understand that my employer will notify me in advance of any changes in the amount that will be deducted from my paycheck.

This authorization also serves as notice for my employer to deposit all or a portion of my pay into any direct deposit account or credit union account which I have designated.

Last Name                                                           First                                                                  Middle Initial
Account number

I am paid: 	 weekly
 bi-weekly

  $	 
(Deduction Amount)

 semi-monthly
 monthly
 pension

Employee Signature 	Date

Northeastern Retail Lumber Association 12-11