Recreation Center Payroll Deduction Cancellation

Employee Information
Full Name
UNG ID #
Department
Job Title
Phone Phone - ### - ### ####
Email
Membership Cancellation Options
Employee Membership Only Employee PLUS Dependent Membership
Dependent Name
Dependent Date of Birth Dependent Date of Birth / MM / DD YYYY
Dependent Name
Dependent Date of Birth Dependent Date of Birth / MM / DD YYYY
Dependent Name
Dependent Date of Birth Dependent Date of Birth / MM / DD YYYY
Dependent Name
Dependent Date of Birth Dependent Date of Birth / MM / DD YYYY
Dependent Name
Dependent Date of Birth Dependent Date of Birth / MM / DD YYYY
Payroll Deduction Cancellation

Please discontinue the above membership(s) for the Recreation Center.
I am paid:

I am paid: Bi-Weekly Monthly 10 Month Faculty ($15/member, per pay period)
Reason for Cancellation
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Draw or Type

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Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY