BH Employee Donation Form 2023

Employee Name*

First NameLast Name

Employee Number *

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

I wish to support the 2023 Employee Giving Campaign with the following donation/order (check one):

$16 per pay period ($400 total) 15 Raffle Tickets + Carharrt Jacket (unisex sizing only) OR Soft Shell Jacket and Puffer Vest.

If you chose option 1, please choose color and size for either the Carhartt Jacket or Soft Shell Jacket and Puffer Vest.

Carhartt JacketSoft Shell Jacket & Puffer Vest

1. Carhartt Jacket Color:

1 .Carhartt Jacket Size:

1 .Soft Shell Jacket Style:

1 .Soft Shell Color:

1 .Soft Shell Jacket Size:

AND

1. Puffer Vest Style:

1. Puffer Vest Size:

1. Puffer Vest Color:

$11 per pay period ($275 total) 10 Raffle Tickets + Soft Shell Jacket

2. Soft Shell Jacket:

2. Soft Shell Color:

2. Soft Shell Jacket Size:

$6 per pay period ($150 total) 5 Raffle Tickets + Puffer Vest

3. Puffer Vest:

3. Puffer Vest Color:

3. Puffer Vest Size:

I would like to make a one time donation of blank

I understand by entering into the drawing my donation is no longer tax deductible.I would like my donation to be a tax deduction and did not receive raffle tickets.

Initials*

Payment: Please Choose One

Cash/CheckPayroll DeductCredit/Debit Card

Only for Credit/Debit Card Payments

Donation Option 1

15 Raffle Tickets + Carharrt Jacket (unisex sizing only) OR Soft Shell Jacket and Puffer Vest

$400.00 Quantity

Donation Option 2

10 Raffle Tickets + Soft Shell Jacke

$275.00 Quantity

Donation Option 3

5 Raffle Tickets + Puffer Vest

$150.00 Quantity

Total

$0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

By signing this form, I certify that I am the employee listed above and I authorize Bingham Memorial Hospital (BMH) to deduct from my paycheck and remit to Bingham Healthcare Foundation. I agree to remit cash to BMH should my earnings be insufficent to allow said deduction.

Employee Signature*

Date*

Date