1. No category

SRmax Payroll Deduction Authorization
Employee Name
Social Security Number
Store Location
Gender
New Hire
YES_______
NO________
Manager
YES_______
NO________
Style
Size
Cost
Shipping
$5.95
Sub-Total
Sales Tax
Total Cost
Sub-Total
x .0675
I authorize Fulenwider-Phoenix Food Service to deduct the “Total Cost” above from my
wages for 1 pair of SRmax slip resistant safety shoes. I understand that I am not
required to purchase my shoes from SRmax, or to purchase my shoes through the
company payroll deduction plan. I understand that my RGM is available to explain other
options for purchasing approved slip-resistant shoes.
Signature________________________________
Date___________________
(For new hires, please submit this information on the New Hire Web Form and send this form to the
office in the weekly packet. For existing employees, please fax this from to Tomra Martin at
828-430-8463 and send the original in the weekly packet.)