Payroll Deduction Form

First Name: Required Field

Last Name: Required Field

Primary E-mail: Required Field

Work Email Required Field

Job Title:

Employee ID Required Field

Campus Address: Required Field

Home Address 1 Required Field

Home Address 2

City:

State:

Zip:

Preferred Phone Required Field

Spouse or Significant Other's Name (if applicable):

Life* - $1000

$100 for 10 months ($50 per paycheck, 20 pay periods)
$250 for 4 months ($125 per paycheck, 8 pay periods)
$500 for 2 months ($250 per paycheck, 4 pay periods)

* Each membership is a household membership, which includes the primary member plus his/her spouse or significant other living at the same address. Please note in the comments box if you would not like to include your spouse or partner.

Please indicate the amount per paycheck that you wish to withhold Required Field

Please indicate the amount per paycheck that you wish to withhold $50 for 20 pay periods
$125 for 8 pay periods
$250 for 4 pay periods

If you would like to select a different amount and number of pay periods, please contact us at 479-575-2801.

Please select your appointment type. Required Field

Please select the date you would like your payroll deduct to begin. Required Field

Open the calendar popup.