NORTH TEXAS MEDICAL CENTER Employer Name Preferred Donation Method First Name Employer Options - Select One - None -Payroll Deduction Check Cash Credit Card My Contact Information Last Name Donor Notes Choose One: - Select -Ongoing Payroll Deduction One-Time Payroll Deduction Home Address Location/Department Name Amount Per Pay Period One-Time Payroll Deduction Amount City Employee Number Frequency you are Paid - Select -Bi-Weekly (26 times/yr) Other State - Select -Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming If other, what frequency: Zip Code Amount of Check Email Address Amount of Cash Office Phone Cell Phone Submit