Your gift will support Mercy Hospital and Medical Center’s new Cancer Center and help us to continue to provide state-of-the-art cancer treatment for all our patients.
1. YOUR GIFT OR PLEDGE AMOUNT
$100 $250 $500 $1,000 Other (please specify amount) $2,500 $5,000 $10,000 $
$100 $250 $500 $1,000 Other (please specify amount)
$2,500 $5,000 $10,000 $
2. PAYMENT SCHEDULE
Single Payment - One Time Gift Quarterly Gift (The above pledge amount will be divided into 4 equal payments) Semi-Annually Basis (The above pledge amount will be divided into 2 equal payments) Bi-weekly Payment (Via payroll deduction - MERCY EMPLOYEES ONLY) Deduction Amount $ Number of Weeks Example: $3.85 for 13 weeks = $50.00; $1.92 for 26 weeks = $50.00
Single Payment - One Time Gift
Quarterly Gift (The above pledge amount will be divided into 4 equal payments)
Semi-Annually Basis (The above pledge amount will be divided into 2 equal payments)
Bi-weekly Payment (Via payroll deduction - MERCY EMPLOYEES ONLY)
Deduction Amount $ Number of Weeks Example: $3.85 for 13 weeks = $50.00; $1.92 for 26 weeks = $50.00
3. YOUR BILLING INFORMATION
Salutation First Name A value is required. Last Name A value is required. Department (MERCY EMPLOYEES ONLY) Address A value is required. Address Two City A value is required. State A value is required. Zip A value is required. Contact number A value is required. Fax number E-mail Address A value is required.
Salutation First Name A value is required.
Last Name A value is required.
Department (MERCY EMPLOYEES ONLY)
Address A value is required.
Address Two
City A value is required.
State A value is required.
Zip A value is required.
Contact number A value is required.
Fax number
E-mail Address A value is required.
4. PAYMENT METHOD
Visa Mastercard American Express Discover Credit card account No.: A value is required. Expiration: A value is required.
You have one more screen to confirm your gift contribution.
