6500 Excelsior Blvd, St. Louis Park, MN 55426 | 952-993-5023 | foundation@parknicollet.com



Park Nicollet Foundation: Payroll Deduction Donation Form

Your donations to Park Nicollet Foundation make good happen in our community. You positively impact the lives of patients, members and colleagues. Thank you for your support!

Reminder: If you are a Park Nicollet Sustainer (an employee who has committed to continuing your giving annually), please do not fill out this form. You will receive an email from Park Nicollet Foundation confirming your sustaining donation. If you wish to make changes, reply to that email. Or, if you’d like more information on how you can become a Park Nicollet Foundation sustainer contact foundation@parknicollet.com.

This form is for payroll deduction donations only. Please visit the Park Nicollet Foundation page if you wish to make a donation by credit card.

Park Nicollet community support:
Organization-wide support:
($) dollar amount
example: 12.50

Thank you for supporting the ONE Employee Giving Campaign with your contribution. Your generosity truly makes an impact in the lives of those in our community. When 26,000 people each offer a little help, amazing change is possible.

A letter will be sent to acknowledge your donation. Your gift is tax deductible to the extent provided by law, and Park Nicollet has not provided any goods or services in exchange for your gift.

My entering my initials below, I authorized these donations to be taken out of my paycheck. I understand that if I check sustaining donor that I will have the option to change or stop my contributions each year during the ONE Campaign.

Note: Please visit the Park Nicollet Foundation page if you wish to make donations by credit card.
Park Nicollet Foundation programs:
Title:
*State:
Apply my dollar ($) donations to (please select at least one designation for your gift):
Apply my dollar ($) donations to (please select at least one designation for your gift):
HOPE Chest:
HOPE Chest:
*How I would like to contribute (please choose one):
*How I would like to contribute (please choose one):
You may choose to have your gift split evenly over 12 or 24 pay periods for one year (please choose one)
What year would you like the deductions to begin?
you may choose to have your gift split evenly through pay periods for one year beginning.
What year would you like the deductions to begin?
Sign me up to be a sustaining donor! Sustaining gifts will continue until you request a change. You will have an annual opportunity to increase, decrease, discontinue or reallocate your gift.
Sign me up to be a sustaining donor! Sustaining gifts will continue until you request a change. You will have an annual opportunity to increase, decrease, discontinue or reallocate your gift.
Initials
If you have any comments or notes regarding your gift, please write them here: