Membership Cancellation Form

Student Affairs

If you see this don't fill out this input box.

*First Name

Middle Initial

Last Name

*草榴视频 ID #

*Extension

*Email

*Payroll Deduction Cancellation Date

*Payroll Deduction Amount

*Previous Payroll Deduction Frequency

MonthlyBiweeklyOne-time Deduction

I am a benefits-eligible 草榴视频 State University employee and I hereby request that 草榴视频 State University cancel the deduction for Recreation or Recreation and EFC Membership Dues from my paycheck as indicated above.

I understand that requests submitted after the 20th of the month, will not be processed until the following month as to not interfere with payroll processing.

*Electronic Signature