Computer Purchase Loan Plan Page 2

COMPUTER ELIGIBILITY FORM

Human Resources:

I hereby authorize that _________________________________________________ is a benefits-eligible

employee. The employee is eligible for a _______ month ______ bi-weekly payment schedule.

Date: ________________________________

Signature: _____________________________________________________________

Human Resources Representative

BUSINESS OFFICE:

The term of the loan is as follows:

Biweekly Payment Amount: $________________

Begin date: ____________________

End date: ____________________

Signature: ____________________________________________________________

Business Office Representative

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Parent category: Financial