Hancock Health Physician Payroll Deduct

Future in Focus Physician Payroll Deduction

FUTURE IN FOCUS PHYSICIAN GIVING FORM

Generous donations from physicians like you can make a tremendous difference in meeting the goal of this campaign and enabling Hancock Health to increase PET scan capacity with a cutting-edge Digital PET/CT scanner … making health possible for all of East Central Indiana.

ファーストネーム *

苗字 *

Street Address *

市 *

State *

ZIP code *

Eメール *

Department *

I will contribute

Select choice:

$10.00 per pay ($260/year)

$25.00 per pay ($650/year)

$50.00 per pay ($1,300/year)

Other $_____ per payOther $_____ per pay

In lieu of per pay period, I will make a ONE TIME payroll deduction in the amount of $_______:

Authorization

*All pledges are payable over two years. Gifts of $10,000 and up will be recognized on a campaign donor wall near the PET/CT scanner and in the Hancock Regional Hospital lobby.

I authorize my employer to deduct from my earning, the amount stated above.
I understand this will remain in place until I either change or cancel it by notifying the Foundation office in writing.
For more information, please call (317) 468.4106

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