MHCC Employee Partner Enrollment Form

MHCC Employees can partner with the Converse County Hospital Foundation for as little as $1 per pay period. Start and stop dates are determined by the employee. Please join us as a MHCC Employee Partner!

I authorize the following Bi-Weekly MHCC Payroll Deduction Amount (24 pay periods per year).

(Authorization is in effect until the stop date listed below or when the recurring gift is cancelled in writing to the Foundation by the employee. Human Resources is authorized to disclose address changes or employment status changes to the Foundation.)

Payroll Deduction

Start date

Start & end date should be the same payroll date.

End date

Deduction amount

$1 each pay period ($24 / year)$2 each pay period ($48 / year)$3 each pay period ($72 / year)$4 each pay period ($96 / year)$5 each pay period ($120 / year)$10 each pay period ($240 / year)$20 each pay period ($480 / year)Other amount each pay period

If 'Other', specify amount per pay period

Only required if you selected 'Other' above.

One-time gift (optional)

Enter an amount to add a one-time credit-card gift on top of your payroll deduction. Leave blank if you only want the payroll deduction.

Signature authorization

Use your mouse or finger to draw your signature in the box above.

Employee Information

First

Last

Employee #

Contact (optional)

Address

City

State

Zip

Phone

Payment (only if you entered a one-time gift)

Card details

If you entered a one-time gift above, your card will be charged for that amount. Card information is sent directly to Authorize.net — the Foundation never sees or stores it. If you are only enrolling in payroll deduction, you can leave these fields blank.

Card number

Expiration (MM/YY)

CVV