Change Contribution |

Change/Cancel Contribution Form

Payment Options*

I would like to change from payment by personal check to payroll deduction
I would like to change the amount of my existing payroll deduction
I would like to cancel my contribution

Please accept my personal contribution of:*

I, , hereby voluntarily authorize Republic Services to deduct from my payroll check each pay period to be remitted in my name to Republic Services Employees for Better Government PAC until such authorization is changed by me in writing. The payroll deductions for my contributions to the political action committee should begin on the pay period following submission of this form.

Contributions to Republic Services Employees for Better Government PAC are not deductible for federal income tax purposes.

*I am authorizing regular payroll deduction in the amount noted above.

*I would like to change my regular payroll deduction to the amount noted above.

Name*

First Last

Employee #*

Job Title*

Business Telephone*

Email Address*