Advance on Wages/Salary Agreement

Name of Employee:                                                                                Date:                                     

Location:                                                                                   Length of Service:                               

I,                                                                , request an advance payment of $                         on my wages/salary payable on the payroll date of _____________________. If this request is approved, I would like to receive this advance by ________________________.

Reason for Loan Request (Be Specific):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

I agree to repay this advance through either: 1) one payroll deduction to be made from wages/salary payable the first pay period immediately following the pay period from which this advance is made or: 2) an amount of $__________ (the greater of $50 or 10% of base salary) in equal deductions from the next _________ pay periods immediately following the pay period from which this advance is made.

I also agree that if I terminate employment prior to total repayment of this advance, I authorize the company to deduct any unpaid advance amount from any wages/salary owed me at the time of termination of employment. If at any time my employment is terminated and there is a balance due, I shall pay the balance in full before I receive my last payroll check. Furthermore, if I fail to pay off the loan at separation, I will make arrangements to pay the balance and all expenses associates with collection.

Employee Signature: ________________________________________     Date: ____________

Approved by:


______________________________________________
General Manager or Supervisor
__________________________
Date

______________________________________________
Human Resources Representative
__________________________
Date

______________________________________________
Payroll Representative
__________________________
Date

______________________________________________
Legal Department Representative 
__________________________
Date

______________________________________________
E.V.P. of  Support Services 
__________________________
Date