PPE Upgrade Deduction Form
Authorize and acknowledge payroll deduction for upgraded Personal Protective Equipment (PPE).
Employee Full Name
*
First Name
Last Name
Employee ID Number
*
Department
*
Please Select
Operations
Maintenance
Warehouse
Logistics
Administration
Other
Supervisor/Manager Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
PPE Item to be Upgraded
*
Please Select
Safety Helmet
Protective Gloves
Safety Glasses
High-Visibility Vest
Steel-Toe Boots
Other
Reason for PPE Upgrade
*
Upgrade Cost / Deduction Amount (USD)
*
Effective Date of Deduction
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload Supporting Document (if any)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Employee Signature (Please sign to authorize deduction)
*
Submit Deduction Authorization
Submit Deduction Authorization
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