ROOM RENT

MONTH OF___________________________

1._____________12._____________23._____________

2._____________13._____________24._____________

3._____________14._____________25._____________

4._____________15._____________26._____________

5._____________16._____________27._____________

6._____________17._____________28._____________

7._____________18._____________29._____________

8._____________19._____________30._____________

9._____________20._____________31._____________

10.____________21._____________

11.____________22._____________

A payroll deduction has been requested for the room rent. Please sign your name below.

Driver & Amount For Payroll Deduction

______________________________$________________

______________________________$________________

______________________________$________________

______________________________$________________

______________________________$________________

Total of DriversPart->______________________________

Colonial Trailways Part->___________________________

<--------------------------->Total Of Check->_________________________________



Make Check Payable To:

________________________________________________

Approved By:





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