Transit Pass - City of Regina - Payroll Deduction Authorization

Payroll Deduction Authorization City of Regina Transit Pass

Check one only ( X )

Monthly deduction amount $76.67 (for employees who are paid monthly)

Biweekly deduction amount $35.39 (for employees who are paid bi-weekly)

Employee Name:

Employee Number:

Ministry:

Effective Date:

Sign this form authorizing payment by payroll deduction for a City of Regina transit pass.

I hereby authorize payroll deduction for a City of Regina transit pass. I understand that this deduction authorization is in effect for a minimum of six month. I understand that if the purchase includes one or more adult dependents, the amounts above will increase.

Signature: ______Date:

Please become familiar with the Terms and Conditions by visiting the City of Regina’s website at http://www.regina.ca/Page618.aspx

Routing: Send completed form to: Employee Service Centre 2100 Broad Street Regina, SK S4P 1Y5

Payroll Deduction Authorization – City of Regina Transit Pass Form 03-Feb-2017 Page 1 of 1