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Employee Contribution Form:

Name:(Required)

First Last

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:(Required)

Email:(Required)

I authorize my employer to make payroll deductions from my salary in the amount indicated below to be used as my contribution to the Boys and Girls Clubs of the Nez Perce Tribe.

Contribution Election:(Required)

I wish to contribute a flat dollar amount each pay period to the Lapwai Boys and Girls Club

I wish to contribute a flat dollar amount each pay period to the Kamiah Boys and Girls Club

Contribution Amount: $(Required)

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