Survey - Employee Giving - Payroll Deduction

1. Your Contact Information

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Middle

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Suffix

Professional Suffix

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Street 2:

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2. Field Is Required Please list pledge amount:

3. Field Is Required How would you like to donate?

4. Field Is Required Designate Your Pledge

5. If other, where would you like your donation designated?

6. Field Is Required Employee ID:

7. Field Is Required Last Four Digits of Social Security #:

8. Would you like this gift to be anonymous?

9. Is this gift in honor or memory of someone?

10. If yes, what type of gift:

11. Honoree name:

12. Please inform the following person of my gift (include name and address if applicable) (Maximum response 255 characters, approx. 5 rows of text)

13. Which areas interest you most?:

14. If other, please indicate your area of interest:

Thank you for supporting Cincinnati Children’s!