Employee Payroll Deduction Form

First Name*

Last Name*

Employee ID#:*

Email*

Address*

City*

State*

Zip Code*

Amount of Deduction:*Amount of deduction per pay period. (Example: If you authorize a $10 deduction per pay period you will contribute $260 in a yearly period.

I would like my donation directed toward:(*)*

General Fund

Canby

Granite Falls

Jackson

Luverne

Pipestone

Worthington

Please specify the scholarship you wish to support(optional)

May we include your name in the publicity of our donors? This authorization includes, but is not limited to, publications and our donor listing on the Foundation page of the Minnesota West web site.

Yes

No

If yes, my name should appear in the publicity as:

Thank you for supporting the Minnesota West Foundation! This enrollment form will be forwarded to the Minnesota West Foundation for processing. Implementation of this deduction will take place approximately 4 weeks after enrollment.

Employee Payroll Deduction Form

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