Monroe Clinic's Employee Relief Fund

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* 1. Employee Information

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* 2. I wish to donate CTO.  Please deduct __________________ hours from my CTO bank (restrictions apply).

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* 3. I authorize $ ________________ per pay period to be deducted from my check until further notice.  (To end a deducted gift payment, you must notify the Foundation Director at least 2 weeks in advance of the end date).

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* 4. I will send my check of $________________ to The Monroe Clinic & Foundation office.  To pay with a credit card or set up a pledge payment cycle, contact Jane Sybers 324-2868

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* 5. A one-time gift of $____________________________

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* 6. Your printed name below constitutes your electronic signature for us to follow your instructions on how you would like to make your gift to the Employee Relief Fund.


Thank you for contributing to The Monroe Clinic Employee Relief Fund to help others in need within our Monroe Family.

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