Team Building Payroll Deduction Form Team Building - Universal Title Mr.Ms.Mrs.MissDr.Other Title Name * Name First First Last Last Employee ID Number * Find My Employee ID Email Address * Phone Number * Address * Address Street Address Street Address Street Address 2 Street Address 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Department/Care Division/Institute * Select a fund...Anesthesiologist Team Building FundAnesthetist Team Building FundCancer Team Building FundCardiology Team Building FundEmergency Medicine Team Building FundHospitalist Medicine Team Building FundMedicine Specialty Team Building FundOB/GYN Team Building FundOrthopedics Team Building FundPediatrics Team Building FundPrimary Care Team Building FundRadiology Team Building FundSurgery Team Building Fund Donation amount (per pay period) * $200$100$50$20Other Donation amount (per pay period) Enter your full name to sign this form * Date * Terms & Conditions Yes, I Agree I authorize a recurring payroll deduction in the amount indicated per pay period as my gift to the Prisma Health – Upstate Foundation. I understand that at any time, I can raise, lower or cancel my contribution by notifying the foundation via email or in writing. CAPTCHA Submit If you are human, leave this field blank.
