Payroll Deduction Authorization Form

Name*

First Last

Email*

G Number*

Department*

Campus Phone*

Total Annual Amount Pledged (minimum of $100)*

Please enter a number greater than or equal to 100.

I am joining the:*

I authorize the Payroll Department of Missouri Western State University to deduct*

Annual Payment Amount*

One-time Payment Amount*

Month to be Deducted*

Amount to Deduct Each Pay Period*

My pay periods are:*

Signature