Shopping Spree

Live Drawing at 6pm on Friday, December 8, during the Dillard’s Shopping Event at Dillard’s in Greenwood Mall!
Do not need to be present to win.
Raffle Tickets $25 each. Purchase online using the form below. Employees may use payroll deduction.

For more information, contact Kathy Smith at KASmith@MCHealth.net.

Payroll Deduction form for MCH Employees

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
$1,000 Dillard's Shopping Spree 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
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.