FORM 5: Employee Pay Selection

Store/Department Name:

__________________________________________________

Employee Name:

___________________________________________________

You have multiple options to receive your pay listed below. Please review them and make your selection.

1. Direct deposit. I select direct deposit for disbursement of my pay. I hereby

authorize my employer (LUSH Cosmetics) to initiate deposits for my net pay to
the financial institution I have designated until canceled by me in writing.

____
Initials

This account is for (1) checking ___or (2) savings ___.

2. ADP TotalPay Card. I select the ADP TotalPay Card Payroll Distribution Service,
which allows me to access my wages from anywhere in the U.S. at anytime by
card on payday. I understand that there is no monthly charge for the card.
However, I also understand that there are fees for certain transactions. I have
reviewed and agree to the Money Network Service Fee Schedule and the
enclosed Money Network Service Terms and Conditions.

______
Initials

I authorize LUSH Cosmetics to disburse my pay by direct deposit or my TotalPay debit card account according
to the selection I initialed above. I understand that I can change my pay selection at any time in the future.

________________________

____________

Employee Signature

Date

Attach Voided Check Or ADP TotalPay Card Pay Option Slip Here