Employee Giving Payroll Deductions

Donor Information

Name(Required)

First Last

Recognition Name

I wish to remain anonymous

Yes

Billing Address(Required)

Street Address Address Line 2 City State Zip Code

Department

Phone(Required)

Email(Required)

Employee ID(Required)

Payment Information

Payroll Deduction(Required)

Start Deduction

Change Deduction

Deduct this amount per pay period(Required)

Please enter a number greater than or equal to 1.

Hidden

Number of Pay Periods

There are 26 pay periods in a year.

Estimated annual contribution

Based on 26 pay periods in a year.

I understand that by submitting this form, I authorize the deduction of my Alaska Native Tribal Health Consortium payroll. I understand this deduction will remain in effect until employment separation, or the pledge is canceled by me in writing.

NOTE: Payroll deductions may take 1-3 pay periods to take effect

Donor Information

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Payment Information

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