Employee Deduction Form

Name*

First Last

SSN (last 4 digits)

Department

Email*

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Consent*

I agree to the privacy policy.

I authorize the following short term payroll deduction to the Gala Fund of Washington Adventist University to cover the cost of my Visionaries Gala Ticket. (This short term deduction will be in addition to any current employee payroll deduction you may already be making. If you need to adjust your current payroll deduction, please complete the Employee Pledge Form.

Single Ticket ($400.00) - Please select the payroll deduction you would like to use:

2 month option (4 pay periods) = $100.00 per period
4 month option (8 pay periods) = $50.00 per period
6 month option (12 pay periods) = $33.33 per period

Couples Ticket ($750.00) - Please select the payroll deduction you would like to use:

2 month option (4 pay periods) = $187.50 per period
4 month option (8 pay periods) = $93.75 per period
6 month option (12 pay periods) = $62.50 per period

***If you currently have a payroll deduction donations***

Please discontinue my current payroll deduction while I am following the Visionaries Gala Ticket payment plan. Please resume my current payroll deduction after my Visionaries Gala Ticket payment plan has been completed.