Healthcare Heroes Form | San Mateo County Health Foundation

HEALTHCARE HEROES DONATION FORM

Thank you for your support!

ACKNOWLEDGEMENT (optional)

Send Acknowledgement of Donation to (optional):

PAYROLL DEDUCTION

I would like to donate every pay period (minimum $1.00 per pay period - enter $ in whole numbers)

AUTHORIZATION

I hereby authorize the Controller of San Mateo County to deduct my donation from my earnings each bi-weekly pay period. This authorization shall remain in effect until change is given by written notice from the employee to the Controller’s office.

DONOR RECOGNITION (optional):

I would like to be listed in the contribution list.

Please do not publish my name on the contribution list.

For further information contact John Jurow at (650) 573-2655 work / (650) 333-5634 cell — or email at

San Mateo County Health Foundation

222 West 39th Avenue, San Mateo, CA 94403, Fax: (650) 573-3447

PONY # HOS316 Foundation • San Mateo County Health Foundation is a 501(c)(3) Tax ID #94-3116070

Thank you for your support!