Survey - CancerCare Manitoba Employee Payroll Donation Form

Please complete this form to enroll in the Foundation's payroll giving program.

Full-time and part-time employees are eligible for payroll giving.

EMPLOYEE INFORMATION

Please enter the following information:

*

Name:

First Required	Last Required

*

Email: Required

Yes, I would like to receive email from CancerCare Manitoba Foundation

Keep me logged in. What's this?

*

Question - Required - Employee ID (found on your ID badge)

*

Question - Required - Department

*

Question - Required - Home Address:

*

Question - Required - City:

*

Question - Required - Province:

*

Question - Required - Postal Code:

*

Question - Required - Phone:

*

Question - Required - I wish to remain anonymous

PAYROLL DONATION

*

Question - Required - Donation per pay period

$4

$5

$10

$25

Other

Question - Not Required - Please complete if you selected "other" in the section above.

Question - Not Required - OR would you rather make this a one-time gift?

*

Question - Required - Making a selection in this box acts as an electronic signature authorizing CancerCare Manitoba Foundation to process your bi-weekly payroll donation.

Join the Payday Pool Lottery for a chance to win over $200 every pay period!

Your gift will continue in perpetuity. To pause, change or cancel please submit a request in writing via email to Sharon Loewen at sloewen16@cancercare.mb.ca.

The personal information you have provided on this form is required to administer and recognize your donations. Your personal information will be shared with payroll. Your personal information is protected under Manitoba's Freedom of Information and Protection of Privacy Act (FIPPA).

Please click the "Submit Registration" button below to finalize your form.