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Personal Information

i.e. Maiden Name
2 digit state code (Example: OK)
xxx-xx-xxxx
mm/dd/yyyy
xxx-xxx-xxxx
xxx-xxx-xxxx
Yes No
mm/dd/yyyy

PLEASE READ AND SIGN THE FOLLOWING:                                              

I hereby authorize EJPPG, Inc. to deduct from my paycheck any of the following that might be applicable:

  • Any overnight tabs and a $10.00 service charge for each tab                         
  • Any returned checks written by me to the company and a service charge for any returned checks not processed by the collection agency.                                           
  • Any Visa, MasterCard, Discover or American Express transaction that is uncollectible due to my error
  • Any monetary shortages resulting from sales, or cash, I am responsible for
  • Any customer charges that I do not get complete billing information on (Billing information consists of a business card or complete mailing address and legible signature.)        
  • Any cost of uniforms provided to employees who do not work longer than 90 days.
  • Any customer return I perform in which I do not submit appropriate paperwork, such as a second JC manager's signature.
  • The cost to "rekey" if keys are not returned within 24 hours of termination.    
  • Any amount over $3.00 in which my register drawer is short.

Throughout this form, when I type my signature, I am essentially signing this electronically.  You agree your electronic signature is the legal equivalent of your manual signature on this application.