Employee Giving Program Payroll Deduction Form

Yes, I would like to support Northwell Health

Your information

RequiredPlease enter letters only.First Name*

RequiredLast Name*

RequiredPlease enter letters and numbers only.Employee ID*

RequiredPlease enter a valid email address with the format youraddress@yourdomain.Northwell Email*

RequiredHome address*

RequiredCity*

RequiredState*

RequiredPlease enter a 5-digit ZIP code or a 9-digit ZIP code with a hyphen after the first 5 digits.ZIP*

RequiredPlease enter numbers only.Phone*

RequiredI wish to have my gift anonymous*

Your commitment

RequiredI would like my donation to support

General Programs

Research

Behavioral Health

Cohen Children's

Employee & Family Programs

Military & Veterans Services

Hospital/Service Line

*

RequiredSelect Hospital/Service Line*

RequiredI would like to

create a payroll deduction pledge

update my payroll deduction pledge

*

Payroll Deduction Amount

I authorize the following deduction from my paycheck.*

RequiredPlease enter numbers and a decimal only.Amount per paycheck $*

My payroll deduction is a voluntary commitment, and as such, I can increase, decrease, or stop at any time. My contribution will be automatically deducted from my paycheck beginning within 30 days of receipt of this pledge form and will continue until such time as I request in writing that my pledge be stopped. Your gift is tax deductible.*

Payroll Deduction Amount

I wish to increase my current pledge by:*

Required fieldAdditional amount per paycheck $*

This will be added to your current pledge amount. My payroll deduction is a voluntary commitment, and as such, I can increase, decrease, or stop at any time. My contribution will be automatically deducted from my paycheck beginning within 30 days of receipt of this pledge form and will continue until such time as I request in writing that my pledge be stopped. Your gift is tax-deductible.*

Agreement

AGREEMENT: By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. By signing below, I accept the conditions of this agreement.*

Required

I accept

*

Don't want to give online?
You have other options!

To donate by mail, download our gift form and send it along with your payment information.

To give by phone: call (516) 321-6320 and a member of the Foundation team will assist you.

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