Vizient Point Payroll Deduction

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Payroll Deduct Authorization (check one only)

Employee ID Number

Employee Name

Employee Badge Number (located on back of badge)

Please Check Company

Vizient

After Tax Deduction Amount

Start Date

Cancellation Date

Employee Authorization

I hereby authorized Vizient to initiate the above payroll deduction action regarding my membership dues. I acknowledge that this payroll deduction action will be effective on the pay period with a begin date closest to my join date and that deductions will occur each pay period thereafter. I understand that this payroll deduction action, once commenced, will continue until I provide a minimum of 30 days notice to the Fairways Fitness center in writing or via this form. I understand that no refunds, whole or partial, for membership dues will be given under any circumstances other than Vizient payroll processing error.