Holiday Savings Club

2010-2011 PAYROLL DEDUCTION AUTHORIZATION

Employee Name: ______________________________ Employee Number: ________________
Employee Department: ________________________ I hereby authorize Maria Parham Medical
Center to deduct the following amount from my paycheck for my Holiday Savings Club account.
Amount to be deducted: $________________ Bi-weekly
Employee Signature: ____________________________Date:_______________
______________________________________________________________________________
The information below is required to set up your account
Name: ______________________________________
Address: ____________________________________
Years at current address: _______________________
Social Security #______ ____ _____Driver License # _________________________
(State & Number)
Driver License Issue Date: ___________ Driver License Exp. Date: ____________
Home Phone # (

) ______________Work Phone # (

) ___________________

Date of Birth ______/_______/______Mothers Maiden Name: ________________

Date of Hire at MPMC: _________________ Job Title: _______________________
Employees may join the Holiday Savings Club at the beginning of the club year or at time of hire
after 90 days. Employees may discontinue payroll deduction at any time during the year.
There is a minimum deduction of $25.00 per pay period required. A deposit will be made to
your personal Holiday Savings account by direct deposit each payday. The MPMC payroll
authorization form can be picked up and returned to the Human Resources Department. Checks
will be distributed from Maria Parham Medical Center Human Resources Department the first
week in November.