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* * * IMPORTANT * * *
All persons enrolling with payroll deduction, new or renewal,
must complete this form and send to county office.
New deductible amounts must be sent for accurate payroll deductions.

* * * * * * * * * * *

AUTHORIZATION FOR PAYROLL DEDUCTION

______________________________ County Schools             Date: ______________________________

I, __________________________________ (Full Name) do hereby officially authorize the chief fiscal officer or his/her designated representative, to perform the following deductions with respect to my salary for payment of professional dues.

Check the Proper Choices Below -------------Renewal or New

     WV Association of Secondary School Principals ___Renewal $130.00 ___New $90.00
 
     Nat. Association of Secondary School Principals ___Renewal $210.00 ___New $150.00  
 
     Total Amount to be deducted ___Renewal $340.00 ___New $240.00
 

It is my understanding that the aggregate deduction, when possible, will be calculated for a reduction to my net salary via equal installments per pay period.

If I terminate my employment during the school term, I ________________________________ do hereby authorize said fiscal officer to perform all respective deductions as denoted herein, in full, within my final paycheck.

In executing this request, I do hereby recognize that it is completely binding and cannot be altered, in any manner, during the fiscal year applicable thereto.

Signature _________________________________

Social Security # ___________________________

School __________________________________

Note to County Office:  Please send all payment checks to:

John J. Cole, Executive Driector
WVASSP
269 Ewing Street
Berkeley Springs, WV  25411
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