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									                                  Division of Recreational Sports
                                         Purdue University

        Payroll Deduction Authorization for Annual Membership
                                              Please print clearly

Date:                                                   PUID:

                Last                                        First                            Middle
Campus Email:                                                        Campus Phone:

Your Purdue University Pay Cycle: (check one)                        Monthly               Biweekly

Membership Type:

         Faculty/Staff                             Faculty/Staff plus Household

         Faculty/Staff plus Dependent              Faculty/Staff plus Family

Membership definition can be found at

I understand and agree to the following terms of payroll deductions:

        The monthly or biweekly deductions will be based on the fee for annual memberships, my
         membership type, enrollment date, and pay cycle.
        Each August the membership rates are subject to change. Members will receive email
         notification by May 1st and a reminder in July each year of the new rate.
        Payroll deduction will remain active until cancellation or change notification is received.
        To cancel payroll deduction, I must complete the Payroll Deduction Cancellation form and
         submit to the Welcome Center in person. Cancellations will not be accepted via email or phone.
         Cancellation forms must be received at least 30 days prior to actual effective date to prevent
         further deductions. Memberships will terminate at the end of the requested month.
        Should I miss a deduction for any reason (leave of absence, termination, etc), I am still
         responsible for payment due. Missed deductions will result in cancellation of membership.

I authorize the Division of Recreational Sports to deduct membership fees from my payroll until my
membership obligation has been fulfilled. I understand that I am responsible for notifying the Division
of Recreational Sports if my pay status is suspended or terminated.

Signature                                                                      Date

                         Division of Recreational Sports Membership Services Use Only

Start date:            Deduction Amount:               Enter Date:             Termination Date:

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