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 Membership Only
Name of membership to be cancelled
Name of membership to be cancelled
Name of membership to be cancelled
Name of membership to be cancelled
Name of membership to be cancelled
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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Full Name

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Date Date / MM / DD YYYY