Hourly
$25 Individual
Newport News Shipbuilding
Company-Sponsored Club
Payroll Deduction Authorization
Salaried
$35 Family
________________________________________________________
Name
_________________
PERNR
_________________
Department
_________________
Work Phone
__________________________________
Building/Location
Home Address
__________________________
City, State
____________
Zip
E-mail Address
NN Shipbuilding – Apprentice Athletic Club
Club Name
2015 – 2016 Membership
Membership Year
By my signature below, I authorize a payroll deduction for the amount noted above to be paid on
my behalf to the club named above for annual dues. I understand that the Payroll Department will
make this deduction in October of each year and that the deduction will continue annually until
such time as my employment terminates or this authorization is canceled by me in writing. I
further understand that any question as to the correctness of the amount deducted shall be resolved
between me and the club, and that the Company will not be responsible for making corrections to
deducted amounts except in the case of clerical errors which the Company will then adjust
promptly.
Signature
Date
DO NOT SEND THIS FORM DIRECTLY TO THE PAYROLL DEPARMENT.
Mail this completed form to:
Mathew Sullivan, Dept. O07, Bldg. 86-3rd floor
or
Apprentice Athletic Club
Building 86-3rd
4101 Washington Avenue
Newport News, Virginia 23607
Attn: Mathew Sullivan
(Forms need to be turned in by October 5, 2015)