Authorization for Payroll Deduction

Date

THE UNDERSIGNED DOES HEREBY AUTHORISE ______________________ (hereinafter referred to as Company) to deduct the amount of $ ____ (dollars) from his/her gross earnings each payroll period beginning ________________________.

In payment for _________________________.

As per agreement, these deductions will continue until the above obligation is paid in full or until employment with said company is terminated for any reason. Should employment be terminated prior to the payment in full of this obligation, the undersigned agrees to pay the balance owed on or before the termination date.

Signature __________________________

Undersigned

Print Name ________________________

Taxation Indentification No: ______ -______-______

Please keep a copy of this for your records.