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2015 Jeep Wrangler Unlimited RUBICON HARD ROCK 4X4
Benefits Relay for Life
2015 Rosebud Employee Payroll Deduction Authorization Form
Employee Name: _________________________________________
Mine Location: __________________________________________
Telephone Number: ______________________________________
I hereby authorize my employer (Rosebud Mining / Trucking Company) to make a one-time payroll deduction
in the amount of:
1
ticket for
$25.00
5
tickets for
$100.00
Please circle your selection
Other (please specify)
tickets for $____________
Employee Signature: ________________________________________________________
2015 Jeep Wrangler Unlimited RUBICON HARD ROCK 4X4
MSRP $49,200.00
Please return payroll deduction forms to the office by Monday, April 27, 2015.
Deductions will take place on the pay date of May 8, 2015.
Raffle is open to Rosebud employees only.