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Employee Payroll Deduction Form

Employee Payroll Deduction Form

By submitting this information, you are giving Gundersen Medical Foundation permission to contact the Payroll department to start the specified payroll deduction amount. Your gift is an ongoing recurring gift unless you elect to change it. We will contact you on an annual basis to update your preferences. Thank you for your generosity.

Please print your name as you wish it to appear on Foundation recognition lists and publications (you may include your spouse/significant other)
Designate recipients Percentage split of gift (if multiple selected)
Recipient entity
Recipient entity
Recipient entity

Select this if you would like an acknowledgement of your gift sent out. 

Memorial and honorarium information

Acknowledgment address
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1900 South Ave.
La Crosse, WI 54601

(608) 782-7300

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