Employee Giving Payroll Deduction

Thank you for supporting Baystate Health through a gift to Baystate Health Foundation.

DONATION INFORMATION

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Question - Required - What is the total gift amount you would like to donate?

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Question - Required - How many Pay Periods should this be spread over? (Note, 26 pay periods equals one calendar year)

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Question - Required - Direct my gift to:

Question - Not Required - If you selected Other above, where would you like the gift to be directed?

Question - Not Required - Employee Number:

Please complete your payroll address.


	Title:
*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province: Required
*	ZIP / Postal Code: Required
	Country:
	Yes, I would like to receive communication from this organization.
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Question - Required - Is this an honor or memorial tribute gift?

Question - Not Required - Please list the name your gift is made in honor or memory of:

Question - Not Required - Notification Recipient Name & Address (we will send this person notification of your gift):

Question - Not Required - Please use this area to include a message with your tribute gift:

Question - Not Required - Additional notes about your gift: