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Payroll Deduction

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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.

Employee Name (Printed)
Employee Signature
Date 

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Payroll Deduction

Skilled Staff

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