Dillard’s Shopping Events

Employment Status*

Full-time Employee
Part-time *Full payment must be made to MCHF by June 6, 2025.

Full payment must be made to Med Center Health Foundation by June 6, 2025.

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 June 6, 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*

Ext.

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 March 28, 2025. (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, March 28, 2025 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 March 28, 2025 and use payroll deduction to pay for them at that time. Do not fill out the payroll form until then.

Please note: If you go on leave prior to the last payment due, you will need to pay the amount as noted above on the last pay period date. If this is not completed and you return to work your total amount will be deducted from your paycheck or if you cease employment with MCH before your balance is paid in full it will be deducted from your last pay check.

Email

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

Dillard’s Shopping Events

Get ready to shop and support at the Dillard’s Spring Shopping Event!

Med Center Health Employees Payroll Deduction Form - Dillard's Event (March 28, 2025)