ECHO Raffle Payroll Deduction Name* First Middle Last Employee Number* Work Phone*Home/Cell Phone*Work Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ECHO Raffle Ticket Quantity* Price: $10.00 Quantity 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 CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
