Payroll Deduct - New Hire

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Thank you for choosing to sign up with Payroll Deduct. Once you submit your authorization payroll will deduct $15 for First Officers, or $25 for Captains on the 15th of every month.

First Name *

Last Name *

Employee Number *

What is Your Current Seat? *

Captain

First Officer

Date of Hire *

Birthday *

Email *

Phone 1 *

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country

Emergency Contact Name *

Emergency Contact Number *

Who, if anyone, referred you to the Fund?

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Additional Monthly Contribution

If you wish to pay MORE than the minimum required donation ($25/month for Captains or $15/month for FOs as of 06/19/25), type that amount here.

Authorization for Payroll Deduction of Membership Dues *

I hereby authorize my employer to deduct my minimum membership dues and any additional donations as indicated above from my paycheck each month and forward it to the G4 Pilot Assistance Fund, inc. I understand that: This deduction will continue until I notify either the G4 Pilot Assistance Fund or my employer, in writing, of my intent to cancel it. AND Membership dues are not refundable once deducted. AND The amount deducted may be adjusted from time to time based on my current seat position (e.g., Upgrading to Captain or Downgrading to First Officer) or the G4 Pilot Assistance Fund’s minimum required donation levels. AND Canceling this authorization may affect my eligibility to receive assistance from the Fund.

Todays Date

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G4 Pilot Assistance Fund, Inc. 😁