AVH Foundation Employee Payroll Deduction Form

AVH Foundation Employee Payroll Deduction Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
AVH Extension
Email
example@example.com
How much would you like to donate?
Amount:
I authorize a payroll deduction to commence on my next paycheck which shall continue until I notify the Foundation office or payroll department of any change.

Gifts will be accepted as unrestricted donations, giving the Foundation the most flexibility to direct the donations to priority programs and projects, unless specified below:
Direct my gift to:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Thank you for your generous support to provide extraordinary healthcare in an environment of excellence, compassion, and trust.

The Aspen Valley Hospital Foundation is a tax-exempt nonprofit organization under section 501(c)(3) of Internal Revenue Code. Gifts may be tax-deductible to the extent permitted by law.
0401 Castle Creek Road | Aspen, CO 81611 | Ph: 970.544.1302 | Fax: 970.544.1164 | avhf@aspenhospital.org
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