Employee Enrollment

Name: Address: City: State: Zip Code: I wish to save tax dollars by participating in the cafeteria plan. I would like the following amounts deducted from my paycheck on a pre-tax basis:	Employer:
	Employee #:
	Date of Birth:	mm/dd/yy

	Check if this is a renewal sign-up
	Please indicate the date of the first deposit:	mm/dd/yy
Medical Expenses $ /pay period for a total of $ /year Dependent Care $ /pay period for a total of $ /year Insurance Premiums Pre-taxed? YES NO	Please indicate the number of paydays from the date of the first deposit through the end of the current year:
	How are you paid?:
	Email:
	Phone:
	Submission constitutes your signature.