Louis Vuitton Handbag Raffle

Payroll deduction form for employees to purchase raffle tickets.

Name*
First Middle Last
Employee Number*
Work Phone*
Home/Cell Phone*
Work Email*
Address*
Street Address City State ZIP Code
Louis Vuitton Handbag Raffle Ticket Quantity*
Price: $25.00
Total
$0.00
Payroll Deduction Full or Split Payment*
You may choose to pay in full or split your payment between two pay periods. The first deduction will occur on your next pay period.
- Pay in full next pay period
- Split between two pay periods (2 or more tickets only)
Authorization for Payroll Deduction*
I hereby authorize the Accounting/Payroll department to deduct the total amount indicated above through payroll deduction. I also understand and agree that in the event my employment with Med Center Health (and/or its affiliated corporations) is terminated before this obligation is satisfied, Med Center Health (and/or its affiliated corporations) may deduct any or all amounts in excess of Federal Hourly Minimum Wage from my final paycheck as consideration for payment on this account and that I will remain responsible for entire balance which will be immediately due and owing. Selecting “I Agree” below is your electronic signature to this agreement.
- I agree
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Comments
This field is for validation purposes and should be left unchanged.

Donated by Dillard’s
Tickets $25
Drawing 12/9/24
Do not need to be present to win.

Fair Market Value = $2,495
Organization License # ORG0002736