HCO BEHAVIORAL HEALTH SERVICES

HCO BEHAVIORAL HEALTH SERVICES
"Helping Youth & Adults lead happier, healthier lives"

11408 Lake Sherwood Ave. N, Suite A

HCO Behavioral Health Services Payroll Deduction Authorization for the purchase of work uniform I authorize HCO Behavioral Health Services to deduct from my paycheck $18.00 for my work uniform shirt(s I understand that the cost of the uniforms will be deducted from my paycheck. I also understand that I will be responsible for all associated costs. I further understand that it is my responsibility to pay for all costs associated with returning any items. If I terminate my position prior to the purchase being paid in full, I authorize HCO Behavioral Health Services to deduct the unpaid balance from my final paycheck.
Date

MonthDayYear
Date
First Name
Last Name
Shirt Color (White, Blue, or Red)
Size (small-2xl)
Quantity
Style (ladies fitted or regular polo)
Please deduct a total of $____
from each paycheck for my order.

By my signature below, I authorize the total amount on this form will be paid via payroll deduction. I understand that if my employment ends prior to the entire amount being paid, the remaining balance will be deducted from my final paycheck
Employee Signature

Clear
Date

MonthDayYear
Date
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