BRANTLEY MANAGEMENT, LLC

Date: ________________________

I _________________________________________________ authorize Brantley

Construction Company to deduct $ _____________ from my paycheck for payment of

items which I have purchased through Brantley Construction Company.

________________________________________

Employee Signature

________________________________________

Superintendent Signature

Check items purchased:

Hard Hat __________

Safety Glasses __________

Tools __________

Other __________

Items Purchased Form.doc