La Grande Fleur 2023
Ticket Payroll Deduction Authorization
Name
*
First Name
Last Name
Department
*
Email
*
example@example.com
Employee Number
How many tickets would you like to purchase?
*
Individual tickets for employees are $250. If you are interested in purchasing group tickets or a table, please contact the IMH Foundation.
How many pay periods would you like to divide your ticket payments across?
*
Pay Period(s)
Subtotal
Payment Per Pay Period
I hereby authorize Ivinson Memorial Hospital to deduct ${paymentPer} bi-weekly from my paycheck, for {howMany} pay period(s), and transmit the amount to the Ivinson Memorial Hospital Foundation.
*
Agree
Signature
*
Submit
Should be Empty: