Employee Fund Drive

First Name Last Name Employee Number
Affiliate Department
Please choose One:
of $ per pay period.
Payroll deductions will begin with the first pay period in 2013.
-- OR --
of $.
           
Card #:
Expiration Date (MM/YY): /
-- OR --
Hours:
I would like my gift to support
Special area or program designation:
For my gift at the $100 level
For my gift of $250 or more
-- OR --
Giving through the United Way
Authorization/Permission
Signature:
Date:
According to IRS regulations, your gift to the Employee Fund Drive is tax-deductible. For further information, please contact the Northeast Health Foundation at 274-0190.
St. Peter's Health Partners
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St. Peter's Health Partners
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2212 Burdett Avenue, Troy, NY 12180