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Survey

Survey

2014 Employee Campaign

Please fill out this form to donate funds to the Employee Campaign through payroll deduction(s) or PDO Donation. Payroll deduct funds will come out of 26 paychecks beginning with the May 16, 2013 paycheck. An acknowledgement receipt will be mailed to your home.

* Indicates required information

Please provide the following information to help us best serve you.

First Name *
Middle Initial
Last Name *
Email *
Department *
Phone *

1.
Name as you would like it to appear on the Donor Wall (if different from above)
2. *
Employee ID Number (this is not your badge number)
3.
YES! I want to support this year's Employee Campaign through payroll deduction. Please deduct the amount selected below from each of the 26 pay periods. ($1 per pay period minimum for payroll deduction) If choosing Other then enter the numerical amount to deduct each pay period (no text)

If Other, please specify:

4.
I wish to make a one time deduction:

Example for $50 one time deduction:
CORRECT ENTRY: 50
INCORRECT ENTRY: $50
5.
I wish to donate PDO hours (less taxes):
- The entire PDO hours donated will be removed from hours accrued on 5/31/10

Example for 20 hours of PDO:
CORRECT ENTRY: 20
INCORRECT ENTRY: 20 hrs
Instruction Check or Credit Card donation - Please make checks payable to NHRMC and mail to Foundation - To make a credit card payment online click here or call Kristal McHugh: 815-5003
6.
Please designate my funds to the following areas: - NOTE: Please do not choose more than two areas

If Other, please specify:


 
 
2131 S. 17th Street, Wilmington, NC 28401  |  910.343.7000