AUTHORIZATION

TO PICKUP WARRANTS

RELEASING

EMPLOYEE:
PLEASE PRINT

_

PHONE EXT:

_

RELEASING

EMPLOYEE
SIGNATURE

_

DATE:

_

SOCIAL SECURITY #:
LAST FOUR (4)

_

IDENTIFICA TION REQUIREMENT:
STATE DRIVERS LICENSE OR STA TE ill #

_

I AUTHORIZE

TO PICK UP THE WARRANTS

CHECKED BELOW

TYPE OF WARRANT: (PLEASE CHECK CHOICES) ALL WARRANTS: PA YlOT WARRANT: TRA VEL CHECK: MEAL CHECK: UNIFORM ALLOWANCE:

----

THIS IS A ONE-TIME AUTHORIZATION PERIOD OF: ------------

TO PICK UP MY WARRANT

FOR THE PAY

PLEASE NOTE:

RECEIVING EMPLOYEE:
PLEASE PRINT

_

PHONE EXT:

_

RECEIVING

EMPLOYEE:

_--=-=-=-:-:-=-=-:-:,-----

_

DATE:

_

SIGNATURE

SOCIAL SECURITY #:
LAST FOUR (4)

_

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