Employee Payroll Deduction Form

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Employee #

Department

T-shirt Size

S
M
L
XL
XXL
XXXL

Donation Amount - I hereby authorize Human Resources to deduct the following amount per pay period from each paycheck. This authorization will continue unless otherwise specified in writing. (copy)

$5 - (HCF CARES Club)
$10
$20
$35
$50

In addition to the above, I would like to give the following amount each pay period to support my teammates through the Employee Assistance Fund.

$1
$2
$10
Other $

For More info Visit https://nmhsfoundation.org/employee-assistance/

If Other $ for Employee Assistance Fund was selected - please include how much you would like deducted per pay period.

Employee Status

Your gift to one of the following programs or facilities will touch people and help provide for their health needs

Electronic Signature (initials) *

Date *

Comment

Or print the form above

print

and mail to:
Health Care Foundation of North Mississippi
830 S Gloster Street
Tupelo, MS 38801

Please contact the HCF office with questions or further assistance:
foundation@nmhs.net or 662-377-3613

Assisting North Mississippi Health Services in its vision to provide the nation's best patient- and family-centered care.

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