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Caring Angel 50/50

Payroll Information

Name:*

Employee Number:*

Number of Tickets:*

I am employed by:*

Department:*

I authorize payroll deduction for the amount selected above:*

Yes

Contact Information

Company:

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country / Location:*

At least one phone number is required.*

Mobile Phone:

Work Phone:

Email:*

Online ordering forms for basket and 50/50 tickets (Employees only) will be available until 11:59 pm on Wednesday, December 10.

BMH Foundation staff will enter your tickets into the drawing. Ticket stubs will be kept in the Foundation office. Your confirmation email will serve as your receipt.

The drawing will be held on Friday, December 12 and winners will be notifie that afternoon. Pick-up will be coordinated at that time. Please email eventrsvp@independence.health with questions

Caring Angel 50/50

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