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Tanzania Payroll Donation
For a team donation, please have each team member fill out a form for their portion of the donation.
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Required
This donation is made by
An Individual
A Team
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Required
Team Name
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Required
Employee ID
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Required
Full Name
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Please select the location where you work.
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Required
Location
<Select>
Clinics
CUMC-Bergan Mercy
Good Samaritan
Immanuel
Lakeside
Lasting Hope
McAuley
Mercy Corning
Mercy Council Bluffs
Midlands
Missouri Valley
Plainview
Schuyler
St. Elizabeth
St. Francis
St. Mary's
<Enter your own value>
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This field is required.
This value is not unique.
Enter your own value
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Required
Department
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Required
I am a national employee
Yes
No
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Required
Please enter a 10-digit phone number. You can use hyphens or periods to separate numerals, and you can put the area code in parenthesis.
Work Phone
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Required
Please enter a valid email address with the format youraddress@yourdomain.
Work Email
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If you do not wish to have your name listed in any donor recognition media, please select the Anonymous box below.
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Required
Anonymous
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Required
Checking this box indicates I understand my information will be entered into the foundation database. Access to database records is confidential.
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I would like my gift to support:
Please select the project you would like your gift to support. PLEASE NOTE: You can support both projects. Your donation will be divided equally.
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Required
Machame Hospital School
Houses for Health
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Gift Information
Required
Please continue my pledge until I notify the foundation to stop.
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I would like my tax-deductible gift to be (select one):
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Required
A one-time gift
A pledge
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Gift Payment: One-time
Required
Payroll Deduction
Hour Club
PTO
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Gift Payment: Pledge
Please select your method of payment:
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Required
Payroll Deduction
Hour Club
PTO
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Payroll Deduction: One-time
Please deduct the following amount from my next paycheck:
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Required
Amount $
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Payroll Deduction: Pledge
Please deduct the following amount each paycheck, for 26 pay periods, beginning the next pay period.
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Required
Please enter numbers and a decimal only.
Amount $
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Amount you would like deducted from each paycheck
Hour Club: One-time
I would like to be a member of the "Hour" club and donate one hour of my pay (or more), to be deducted from my next paycheck.
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Required
Number of hours:
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Hour Club: Pledge
I would like to be a member of the "Hour" club and donate one hour of my pay (or more) per paycheck, for 26 pay periods, beginning the next pay period.
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Required
Please enter numbers only.
Number of hours:
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The number of hours of pay you would like to donate per paycheck.
PTO: One-time
I would like to donate one hour of PTO (or more), to be deducted from my next paycheck.
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Required
Number of hours:
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PTO: Pledge
I would like to donate one hour of PTO (or more) per paycheck, for 26 pay periods, beginning the next pay period.
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Required
Number of hours:
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Digital Signature
I authorize CHI Health to withhold my payroll deduction as indicated above. I understand that the information on this form will only be used to administer this donation.
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Required
Please enter a date with the format M/D/YYYY.
Date:
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M/D/YYYY
Required
Full Legal Name:
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Please enter your name