WKU Payroll Deduction Authorization
I, _______________________________________, _____________________, hereby authorize
First and Last Name (Please Print Legibly)
WKU ID (800#)
Western Kentucky University (WKU) to deduct from my net pay the appropriate amount with regard to my and/or my
spouse/partner’s participation in Weight Watchers® 12-week At Work series. Any deduction will be on a post-tax basis.
I understand that by participating in Weight Watchers® 12-week At Work series, WKU is paying my and/or my
spouse/partner’s enrollment fees upfront and that this sponsorship is conditional on me/us meeting attendance
requirements, i.e., weighing-in and attending at least nine (9) of the twelve (12) weekly meetings. Furthermore, I
understand that if I/we do not attend at least nine (9) meetings that I will be responsible for repaying WKU
approximately one-half the full enrollment fees ($75 for individual or $150 for couple) via payroll deduction. The payroll
deduction will occur in the next available pay period following the 12-week series.
Enrollment Type (Check applicable box)
□ Individual ($75)
□ Spouse/Partner Only ($75)
□ Employee plus Spouse/Partner ($150)
Spouse/Partner’s Name: _________________________________
First and Last Name (Please Print Legibly)
□ Cross-reference secondary member on health plan. (Please check if applicable)
_____________________________
Employee’s Signature
_______________
Date
RETURN TO:
Wade Pinkard, Potter Hall 445
Wade.Pinkard@wku.edu