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5916 Wilson Ave.
St. Louis, MO 63110
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Health & Welfare ACH Payment Authorization
The charge will appear on your bank statement as an “ACH Debit”. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.
I (Full Name)
(Required)
Authorize St. Louis Glass & Allied Industries (Merchant’s Name) to charge my bank account ending in
(Required)
For the following elections:
(Required)
Choose one option
1 lump sum payment of the total amount owed to be taken out on the 1st business day of the quarter selected below.
3 payments, each equivalent to 1/3 of the total amount owed to be taken out on the first business day of each month within the quarter selected below.
Health & Welfare premiums for the quarter selected below. (Description of Goods/Services)
Please Select One:
Quarter 1: Jan, Feb, March
Quarter 2: April, May, June
Quarter 3: July, Aug, September
Quarter 4: Oct, Nov, Dec
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify St Louis Glass & Allied Industries in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that St. Louis Glass & Allied Industries may at its discretion attempt to process the charge again within 30 days, and agree to an additional $_7.50__ charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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Vacation Request
Please note that requests must be received by 4pm on Tuesday in order for any eligible checks to be written the same week.
Company Name
(Required)
Employee Name
(Required)
Employee Email
(Required)
Full Week Dates Requested
Week 1: Start Date
MM slash DD slash YYYY
Week 1: End Date
MM slash DD slash YYYY
Week 2: Start Date
MM slash DD slash YYYY
Week 2: End Date
MM slash DD slash YYYY
Week 3: Start Date
MM slash DD slash YYYY
Week 3: End Date
MM slash DD slash YYYY
Week 4: Start Date
MM slash DD slash YYYY
Week 4: End Date
MM slash DD slash YYYY
Individual Days Requested
Day Request 1
MM slash DD slash YYYY
Day Request 2
MM slash DD slash YYYY
Day Request 3
MM slash DD slash YYYY
Day Request 4
MM slash DD slash YYYY
Day Request 5
MM slash DD slash YYYY
Day Request 6
MM slash DD slash YYYY
Day Request 7
MM slash DD slash YYYY
Day Request 8
MM slash DD slash YYYY
Day Request 8
MM slash DD slash YYYY
Day Request 10
MM slash DD slash YYYY
Total # of Days Requested:
(Required)
Please select how you would like to receive your check:
(Required)
Mail It
Pick It Up
Direct Deposit
Please provide the last 4 of the acct number
Signature
(Required)
Today's Date
(Required)
MM slash DD slash YYYY
Please note the following conditions for Vacation Check Requests:
1. 2 weeks of vacation may be taken as individual days, all additional vacation time must be taken on consecutive days. Vacation time must be submitted in weekly increments (5 days, if available)
2. Holidays cannot be included as a vacation day. Checks can be written up to 30 days prior to the vacation dates submitted.
3. All vacation checks will be issued at the weekly rate outlined by your Journeyman status as of July 1st of the previous plan year.
4. Any check requests outside of these parameters must be submitted to the Vacation Committee for approval.
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