Payroll Deduction


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PAYROLL DEDUCTION FORM

 

# of Items Description $ Cost Amount
# Steel Toe Boots $35.00
# Rubber Steel Toe Boots $20.00
# Leather Gloves $6.00
# Gloves $3.00
# Hard Hat $12.50
# Safety Glasses $3.00
# Safety Vest $13.00
# Safety Goggles/clips,etc. $3.50
# DOTMedcard $60.00
# Motor Vehicle Report $30.00
# Non DOT Physical $40.00
Total Deduction Amount

By signing below, I authorize the total deduction amount to be deducted from my next paycheck.

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Signature Certificate
Document name: Payroll Deduction
lock iconUnique Document ID: ff3554f44f04cb1bfa55ce63487a35a06b4532dd
Timestamp Audit
March 29, 2026 10:07 am CDTPayroll Deduction Uploaded by Skilled Staff - [email protected] IP 46.110.217.61
April 15, 2026 2:20 pm CDT Document owner [email protected] has handed over this document to [email protected] 2026-04-15 14:20:18 - 46.110.217.61
April 15, 2026 3:10 pm CDT Document owner [email protected] has handed over this document to [email protected] 2026-04-15 15:10:54 - 46.110.217.61
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