Ascension Foundation 2020 Campaign - Oshkosh Area United Way

STEP 1: MY INFORMATION

First Name *

Last Name *

Date of Birth *

Home Address *

Home Address

City

State

ZIP Code

Phone Number *

Phone Type *

Email Address *

Email Type *

Ascension Location *

Job Type *

Employee ID *

Department *

I am an employee of:

MedXcel

Touchpoint

TriMedx

STEP 2: MY PLEDGE

PAYROLL DEDUCTION is available to Ascension Associates only. (If you are an employee of R1, MedXcel, Touchpoint or TriMedX please choose from check or bill me options below.) I authorize Ascension to deduct my pledge per pay period or as chosen below (payroll deduction period is February - December 2021):

Investment Options *

= Total Amount *

One Time Payroll Deduction Amount *

Please contact me for my credit card information

Check Amount *

Check Number *

Check Date *

Please make checks payable to the foundation in which you are donating. Write separate checks if donating to multiple entities.

Send me a pledge reminder in January 2021 for the following amount: *

STEP 3: MY GIFT DESIGNATION

Please choose up to 3 funding options below:

Fund Choice #1 Fund Choice #1

Fund Choice #1 Amount - Designation total must match total pledge *

Fund Choice #2 Fund Choice #2

Fund Choice #2 Amount - Designation total must match total pledge *

Fund Choice #3 Fund Choice #3

Fund Choice #3 Amount - Designation total must match total pledge *

TOTAL ASCENSION PLEDGE/GIFT *

Total Ascension pledge/gift amount must equal total pledge amount in 'Step 2: My Pledge'.

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Ascension Associate Giving Campaign

STEP 1: MY INFORMATION

STEP 2: MY PLEDGE

STEP 3: MY GIFT DESIGNATION