Withdrawal Form

Name *

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Last

Employee ID *

Employee Email *

Job Title *

Address

Home Phone Number

Organization *

BCBSM
BCN
Emerging Markets

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Cancel Payroll Authorization *

Payroll deduction is cancelled

I hereby authorize the BCBSM payroll department to cancel the deduction of $4.10 each month from my monthly salary for BCBSM Leadership Development Association dues. I understand this cancellation will be effective for the following month's dues.

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