Donating by deduction at source

Deduction at source form

"*" indicates required fields

Name*

First name Last name

Employee number*

Direction*

Personal address*

Street Address Address Line 2 City Postal code

Phone*

Personal e-mail*

Salary deduction

I authorize the CIUSSS du Centre-Sud-de-l' Île-de-Montréal Payroll Department to deduct from each of my paychecks the amount of:*

Signature

Signature*

Enter your name

Today's date*

Acceptance*

By checking this box, I agree that the CIUSSS du Centre-Sud-de-l’Ïle-de-Montréal’s payroll department may deduct the amount indicated in the “salary deduction” section from each pay.
Please note that by completing this form, you agree to the conditions of use and privacy policy.

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To stop or change a payroll deduction, contact your payroll department.