Employee Giving Employee Payroll Deduction Pledge Form Employee Payroll Deduction Pledge Form Name* First Last Employee Number* Please enter your employee badge number.Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Please know that we do not share your information with other parties.Phone*Email* My Gift to Partner In Health:I would like to help provide quality healthcare services to the Western Slope of El Dorado County and pledge through Marshall Foundation for Community Health as indicated below:Please check applicable box:* Hour Club (one hour of your base salary per pay period. Best employee pledge and recognition. Employees who work less than 60 hours per pay period may join the Hour Club by pledging one-half hour of their base pay per pay period. Check here if that applies to you. $650 / $25 per pay period $520 / $20 per pay period $390 / $15 per pay period $260 / $10 per pay period $130 / $5 per pay period Other: See Below Other Amount (please enter 0 if selection is made above):* Please enter the amount you would like to contribute per pay period.Please use my gift for:* Where the need is greatest Other: (please specify below) Other Support:* Tell us the area or fund you would like to support. Please enter "NA" if selection is made above.T-Shirt Orders - Currently Breast Cancer AwarenessIf you are ordering a T-Shirt for the Breast Cancer Awareness T-Shirt, please indicate your size and style (Women's V-Neck; Women's Crew Neck; Men's Crew Neck) Breast Cancer Awareness T-Shirts are $20 each.T-Shirt Orders For Employee GivingIf you are donating a regular, ongoing pledge during Employee Giving, you are entitled to the special employee giving T-Shirt at no charge. You must donate $5 or more per pay period to qualify for the free t-shirt. The only style available is the crew neck.Select Size HereXSSMLXLXXLXXLSelect Style Here for Breast Cancer Awareness T-ShirtWomen's Crew NeckWomen's V-NeckMen's Crew NeckCommentsThis field is for validation purposes and should be left unchanged.
