GLEAMNS Human Resources Commission, Inc.



GLEAMNS HUMAN RESOURCES COMMISSION, INC.

STAFF HEALTH ASSESMENT and TUBERCULIN SKIN TEST (FORM 2926)

PAYROLL DEDUCTION AUTHORIZATION FORM

By my signature below, I acknowledge the employment health assessment and tuberculin skin test are my financial responsibility. Due to a personal financial hardship, I am unable to cover the cost of these two assessments, at this time. By my signature below, I further authorize GLEAMNS payroll department to deduct the full cost of the employment health assessment, paid for by GLEAMNS, from my first four payroll deposits, in equal increments.  Should I separate from employment prior to receiving four payroll deposits, I authorize GLEAMNS payroll to deduct the remaining balance in full from my last payroll deposit.

After completing this form, please return to the Human Resources Department via email: hr@ or by fax: 864-223-5985

Print Name: _______________________________ Employee I.D.: _____________________________

Program: _________________________________ Job Title:___________________________________

Vendor: __________________________________ Amount: ___________________________________

Signature: ____________________________________________ Date: ___________________

-----------------------------------------**GLEAMNS HR Use Only**--------------------------------------

Service Provided: ________Non-DOT _________DOT ________PPD (Tuberculin Skin Test)

Appointment Date: ___________________________ Cost of Assessment: _______________________

Employee: __________________________________ Date received: ____________________________

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