Historical Society and Museum
PAYROLL DEDUCTION AUTHORIZATION (DED/ORG CODE - 089/057)
Name
*
First Name
M.I.
Last Name
Social Security #
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
I hereby authorize the State Controller's Office to deduct from my salaries and wages the amount designated below for membership as a supporting member of the above named organization. THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL CANCELLED BY ME OR BY ABOVE NAMED ORGANIZATION.
I authorize:
*
$5.00
$10.00
$20.00
Signature
*
Clear
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*
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