Thomas Memorial Hospital Foundation

500 Poplar Street Suite 300

304-766-4357

 

EMPLOYEE CLUB PLEDGE FORM

 

YES!  I want to join the Employee Club and support the many programs through Payroll Deduction.

 

Gift per paycheck:   $1_____  $2_____  $3_____  $4_____  $5_____ $10_____ Other $_____

 

One-time gift by cash or check:  $_____

 

Name:  ________________________________	Dept:  _________________________________
Phone: (work) ___________________________	SSN:  _________________________________
Signature: ______________________________	Date:  _________________________________