Prisma Health OB/GYN Education Fund Payroll Deduction Form

Make a gift in support of the OB/GYN Education Fund to help provide OB/GYN resident and fellow education, travel, faculty development, wellness initiatives, and recruitment activity in the Upstate.

Thank you!

Please complete this form to authorize payroll deductions. The anticipated start of deductions is within the next three pay periods.

For more information, please contact us.

Prisma Health OB/GYN Education Fund Payroll Deduction Authorization Form

Personal Information

Title Title

Name

First

Last

Address *

Address

Street Address

Street Address 2

City

State/Province

Zip/Postal

Email Address *

Phone Number *

Yes, This is an honor or memorial gift

Honoree/Memorial Name:

Work Information

Employee Number *

Department Name *

Hospital/Dept Number

If you are on the Prisma Health Network, find your Employee ID Number Here. If you are not on the network, your Employee ID Number can be found on Workday under your “Job Details” page.

Donation Information

Donation amount per period

Use slider below to choose number of pay periods for deductions (One full year is 26 pay periods)

Donation amount per pay period

Total number of pay periods

Total donation

Signature

Enter your full name to sign this form *

Date *

CAPTCHA

If you are human, leave this field blank.