St. Luke Employee Giving Program Enrollment Form
Name
First Name
Last Name
Department
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Submitted (Today's Date)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please Deduct (check one):
$5 per paycheck ($120/year)
$10 per paycheck ($240/year)
$25 per paycheck ($600/year)
$50 per paycheck ($1,200/year)
Other - Please Specify (minimum participation is $1 per paycheck)
If you checked "Other", please specify how many dollars you would like deducted per PAYCHECK
By selecting "Yes", I authorize the deductions requested above. I believe strongly in the work we do here at St. Luke. I want to go above and beyond the valuable time I give, and give a little extra. I recognize that participation in this program is not mandatory, and any contributions will be accepted. Changes may be made at any time upon written request to the HR department.
Please Select
Yes, I authorize this action
Please Note: Deductions will only be taken from 24 of each year's 26 pay periods. Contact the HR Department with any questions.
Submit
Should be Empty: