UNIFORM ORDER FORM

This order form is to purchase Company uniforms that will be directly deducted from your paycheck. As these are being issued to you, you are responsible for the maintenance, laundry and/or care of these items. All uniform items must be kept neat and clean and in good condition at all times.

Uniform Item(s)
Quantity
Size
Cost
Total
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Total amount split over 9 week paycheck - Payment amount per paycheck
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Acknowledge and Agreement

I hereby authorize Integro Professional Services to make the deduction(s) described above from my wages each pay period as outlined above. This withholding should begin immediately and continue until the obligation is paid in full. I agree that in the event of the termination of my employment for any reason, the entire amount due and owing becomes immediatelydue and payable and will be deducted from my final paycheck(s). I understand that to revoke this authorization I must submit the revocation in writing to my immediate supervisor and that it will become effective after receipt and processing by Integro Professional Services Nothing in this Authorization shall be construed to limit the at-will employment relationship between myself and Integro Professional Services.

Associate Signature

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