Dillard’s Shopping Events

Employment Status*

Full-time Employee
Part-time *Full payment must be made to MCHF by Feb 14, 2025.

Full payment must be made to Med Center Health Foundation by October 25, 2024

This is to authorize the Accounting/Payroll Department to deduct the Amount (not to exceed $250 per event) over the specified number of pay periods or by February 15, 2025.. (Deductions will begin next pay period.)

I agree to have the above listed amount paid through payroll deduction. I also understand and agree that in the event my employment with CHC (and/or its affiliated corporations) is terminated before this obligation is satisfied, CHC (and/or its affiliated corporations) may deduct all amount 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 by said date above.

Amount*

$50 minimum, $250 maximum

Number of Pay Periods*

Employee Name*

First Last

Employee Number*

Email*

Entity*

TMC Bowling Green
TMC Scottsville
TMC Franklin
TMC Caverna
TMC Albany
TMC Russellville
Commonwealth Health Corporation

Department*

Cell Phone #*

Options for delivery*

Mail to address below. ** If you do not receive the gift card within 10 business days, please email kasmith@mchealth.net.
Pick up at Dillard’s Greenwood Mall on December 6, 2024. (You will be able to shop immediately with your card. Please make sure you have your badge with you.)

Choose one option to receive your gift card. If you receive two cards in error, please contact kasmith@mchealth.net.

Address*

Street Address City State ZIP Code

PRE-SHOP: You will pick up your items downstairs near Hosiery on Friday, August 9 and use payroll deduction to pay for them at that time. Do not fill out the payroll form until then.

Please note that if you go on leave of absence or are terminated before the gift card is paid in full, you will need to make arrangements to pay the balance due. You can contact kasmith@mchealth.net to make arrangements.

PRE-SHOP: You will pick up your items at Dillard’s in the Hosiery Dept. on December 6, 2024 and use payroll deduction to pay for them at that time. Do not fill out the payroll form until then.

Phone

This field is for validation purposes and should be left unchanged.

Med Center Health Employees Payroll Deduction Form – Dillard’s Event (December, 6 2024)