Employee Relief Fund (ERF)

Monroe Clinic's Employee Relief Fund

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* 1. Employee Information

Name

Employee ID

Address

City/Town

State/Province

ZIP/Postal Code

Department Name

Date

Phone Number

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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.

Electronic Signature:

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