Make a gift in support of the Peter Tilkemeier, MD Department of Medicine Fund

Thank you for supporting the Peter Tilkemeier, MD Department of Medicine Fund. You are helping to connect and inspire our department to build our internal community so we can continue to learn and grow.

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

For more information, please contact Cyndie Ford, Upstate Foundation, by phone at 864-797-7744 or by email at Cynthia.Ford@prismahealth.org.

Prisma Health Department of Medicine 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 (26 = Full year)

Donation amount per pay period

Total number of pay periods

Yearly donation total

Signature

Enter your full name to sign this form *

Date *

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