Give Explore Giving Employee Giving Payroll Deduction One Time Gift Contact Us Meet the Team UNTHSC Foundation Board Employee Giving Events HomeGiveEmployee GivingRequest Payroll Deduction Gift Menu Explore Giving Employee Giving Payroll Deduction One Time Gift Contact Us Meet the Team UNTHSC Foundation Board Employee Giving Events Request Payroll Deduction Gift Please complete the form below and click submit to make an employee giving gift through payroll deduction. Contact InformationName(Required) First Name Last Name Work Email(Required) Department Employee ID(Required) Home PhoneWork PhoneAddress(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Gift InformationI would like my gift to remain anonymous.YesNoI would like the AMOUNT LISTED BELOW DEDUCTED from my paycheck EACH MONTH over a 12 MONTH PERIOD beginning in the October 2024 pay period, and ending in the September 2025 pay period. EXAMPLE: If you'd like to make a $120 gift over a 12 month period, enter $10.00 in the first box (Dollar Amount Deducted Each Month) and $120 in the second box (Total Dollar Amount for the Fiscal Year), $10 x 12 months = $120. Payroll deduction is only available for a $2 minimum gift amount made over a 12 month period - no exceptions can be made. Dollar Amount Deducted Each Month(Required)Please enter a number less than or equal to 9999.TOTAL Dollar Amount for the Fiscal Year (Amount listed above X 12 months)(Required)Please enter a number less than or equal to 9999.Please designate my payroll deduction gift to:(Required)UNTHSC School of Biomedical Sciences Annual ScholarshipUNTHSC School of Health Professions Annual ScholarshipUNTHSC College of Nursing Annual ScholarshipUNTHSC College of Pharmacy Annual ScholarshipUNTHSC School of Public Health Annual ScholarshipUNTHSC TCOM Annual ScholarshipHorsman McFadden HSC Employee Endowed ScholarshipUNTHSC Student Emergency FundUNTHSC Foundation Annual FundOtherI’d like to designate my gift to more than one fundPlease specify a designation for your gift.(Required) If you want to divide your gift among multiple funds, you can specify here which funds and how much to designate for each.(Required)ConsentConsent(Required) I agree to having the amount defined above automatically deducted from my monthly pay checks.(Required)By checking this box you authorize HSC to deduct the total monthly gift amount stated above from your paycheck over a 12 month period, beginning October 2024 pay period and ending in September 2025 pay period.CAPTCHA
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