Authorization Renewal For
Payroll Deduction
For Brown Faculty Club Membership Dues.
It’s time to renew your Brown Faculty Club Membership for Fiscal year 2009-2010. Payroll deduction of your annual dues is easier than ever! If you wish to use this convenient method of dues payment, simply complete and return the payroll deduction authorization form below.
Authorization forms must be received no later than August 17th
If you have any questions or need additional information, Please call the Club at 863-3023.
Payroll Deduction Authorization for Brown Faculty Club Membership Dues
I, _____________________________ hereby authorize the Payroll Office of Brown University to make deductions from my paycheck as indicated below and to pay the same to the Brown Faculty Club. Payroll Deduction to be based on a ten month employee pay schedule. Applications received after August 17, 2009 will not be eligible for payroll deduction. Please mail completed application to the Brown Faculty Club, Brown University, Box 1870. Please be sure to complete all information. (Please print)
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$60.00 per year dues for Junior Faculty/Staff (level 11 and below) (10 consecutive payments of $6.00)
Current Pay Schedule: (check one):
□ Monthly □ Weekly □ Semi-Monthly
Social Security #_ _ _ - _ _ - _ _ _ _ Renewal Date ______________________________
$100.00 per year dues for Senior Faculty/Staff (level 12 and above) (10 consecutive payments of $10.00) Signature Required _____________________________________
(for office use only) Membership No. _________ Phone: 863-3023 Fax: 863-3859, www.brown.edu/Facilities/Faculty_Club