For Office Use Only

Perpetual Monthly Check U-Bill

Amount Paid $ Amount Paid $

RECREATIONAL
A
ATIONAL Payroll Deduct Cash
Amount Paid $
SERVICES
Membership Visa/Mastercard/Discover
Amount Paid $ Paid By: (member number)

Last Name First Name M.I.

8-Digit University ID Number Department

Campus Address Campus Phone #

Check the box for each item you are requesting

for Perpetual Payroll Deduct (PPD).
Faculty/Staff Membership Faculty/Staff Family Membership
Faculty/Staff Sponsored Adult Membership
Faculty/Staff Sponsored Dependent 418 Locker Rental: Locker #
Membership

Initial each of the statements below stating that you

understand and agree to the following conditions:
I understand that my membership card must be shown each time I wish to access Recreational Services
facilities; I understand that unauthorized use of my membership may result in the revocation of my
privileges. As a Recreational Services member, I accept responsibility for my actions and acknowledge
Initial that behavior conflicting with department polices may result in the loss of my membership privileges and/or
disciplinary actions. I have read and understand the membership code of conduct.

I authorize the University of Iowa to deduct from my monthly paycheck 1/12th of the amount certified as the
designated annual membership rate, and where applicable, the monthly Locker Rental fee. Each months
membership deduction is for the prior months service.
Initial
I understand that, in addition, there is a one time Perpetual Payroll Deduction membership setup fee of $36. And
where applicable, there is a one time Perpetual Payroll Deduction Locker setup fee of $10. These fees must be paid
Initial at time of enrollment.

I understand that by electing payroll deduction, I am agreeing to a minimum six payroll deduction contract and
should I wish to cancel my membership and/or Locker Rental prior to six deductions, I will continue to be charged
Initial until six deductions are reached.

I understand that in order to terminate my participation in the Perpetual Payroll Deduction program, or if my
University compensation changes or stops for any reason (leave of absence, termination, etc.) I must complete the
Initial Payroll Deduction Cancellation form and submit it to Recreational Services Membership Services in person,
via mail, online fax or email. Cancellations will not be accepted by phone.

I understand that should I miss a deduction for any reason, I am responsible for the payment due.
Initial Missed deductions could result in cancellation of membership and if applicable, the Locker Rental.

I understand that refunds/credits will not be issued for previous deductions. Memberships and/or Locker
cancellations for employees in the Perpetual Payroll Deduction Program become effective no earlier than the last
Initial day of the month in which the cancellation notice is received. The final deduction will occur on the next monthly
paycheck after the requested date of cancellation.

/ /
Faculty/Staff Member Signature Todays Date

For Office Use Only Member Sponsored Sponsored Member M/ID#

Membership Monthly Deduction $

Monthly Locker Deduction $

Total $

/ /
Membership Start Date Member Services Employee Initials New Updated