1441325436 smcf payroll deduction fillable

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<ul><li><p>SMC PAYROLL DEDUCTION AUTHORIZATION FORM</p><p>F/L NAME MOBILE PHONE LAST 4 DIGITS OF SS# </p><p>MAILING ADDRESS PERSONAL EMAIL </p><p>NEW CONTRIBUTIONS: </p><p>PLEASE DEDUCT MONTHLY (CHECK ALL THAT APPLY)</p><p> $___________ Presidents Circle (min $100 monthly, Sept Jun) </p><p> $___________ SMC Associates (min $10 monthly, Sept Jun) </p><p> $___________ Other for___________________________________ </p><p>CHANGES: </p><p>PLEASE REVISE MY MONTHLY CONTRIBUTION(S) (CHECK ALL THAT APPLY) </p><p> Presidents Circle Revised Amt. $ ___________</p><p> SMC Associates Revised Amt. $ ___________</p><p> Other___________________________________ Revised Amt. $ ___________</p><p>EMPLOYEE SIGNATURE DATE </p><p> PLEASE RETURN COMPLETED FORM TO SANTA MONICA COLLEGE FOUNDATION 1900 PICO BLVD., SANTA MONICA, CA 90405 310.434.4215</p><p>TOTAL $___________ Monthly Deduction</p><p>FL NAME: MOBILE PHONE: LAST 4 DIGITS OF SS: MAILING ADDRESS: PERSONAL EMAIL: fill_6: fill_8: fill_10: Other for: TOTAL 1: 0Revised Amt: Revised Amt_2: fill_12: Revised Amt_3: Date: Assoc Add: PC Memb Add: Other Add: PC Revise: Assoc Revise: Other Revise: </p></li></ul>

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