Prisma Health W. Larry Gluck MD Endowed Chair for Translational & Molecular Oncology Research Payroll Deduction Authorization Form

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, Office of Philanthropy, by phone at 864-797-7744 or by email at Cynthia.Ford@prismahealth.org.

Prisma Health Gluck Endowed Chair 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 *

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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