NORTH TEXAS MEDICAL CENTER Preferred Donation Method Options - Select One - None -Payroll Deduction Check Cash Credit Card Choose One: - Select -Ongoing Payroll DeductionOne-Time Payroll Deduction Frequency you are Paid - Select -Bi-Weekly (26 times/yr)Other Amount Per Pay Period One-Time Payroll Deduction Amount If other, what frequency: Amount of Check Amount of Cash If donating by credit card, please CLICK HERE to exit this form and complete your online transaction. Employer Employer Name Employee Number Location/Department Name My Contact Information Last Name First Name Email Address Home Address City 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 Zip Code Office Phone Cell Phone Donor Notes CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit