Payroll Membership Termination Form Name GWID We hate to see you go! Can you please tell us why you're leaving? Cost Location Leaving GW Dissatisfaction Other… Enter other… What can we do better? Please help us grow. eSignature Date Date: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date: Day Day12345678910111213141516171819202122232425262728293031 By using the e-signature feature of this online application, I represent and warrant without reservation that I have the legal right, power, and authority to agree to all terms contained in the electronic records of this online application on behalf of myself (or on behalf of the individual on whose behalf I am acting, if different). I further agree that my use of the e-signature feature of this online application constitutes an "electronic signature" as defined by the Electronic Signatures in Global and National Commerce Act ("E-Sign") and the Uniform Electronic Transactions Act ("UETA") and that I have formed, executed, entered into, accepted the terms of, and otherwise authenticated the terms specified herein for the use of the e-signature feature of this online application.