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Purchase request by deduction at source - MONALI
1
Personal information
E-mail
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Personal E-mail
Professional E-mail
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Password
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Confirmation email
Personal
Corporate
Title
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Mx
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Doctor
Madam
Mister
Gender
First name
Last name
Job title
Company
Country
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Canada
Province
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Ontario
Quebec
Address
City
Postal code
Phone
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Home
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Cellular
2
Transaction
Single ticket
$100.00
/ unit
x
$
=
Subtotal:
Total:
$
Triple ticket
$250.00
/ unit
x
$
=
Subtotal:
Total:
$
Donation to the project
Subtotal:
Total:
$
Total:
$
No. d'employé LOTO
I confirm that I want to purchase a ticket by deduction at source and that I am an employee of the CISSS de l'Outaouais (mandatory)
Yes
No
In how many installment(s) would you like to purchase your ticket(s)?
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1 versement
2 versements
5 versements
10 versements
20 versements
By completing this form and choosing the method of payment deduction at source, I agree to the number of payments chosen above being deducted from my pay. I also agree to complete my payment commitment to the Gatineau Health Foundation in the event that I am no longer employed by the CISSS de l'Outaouais.
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Non
Oui
3
Payment
TOTAL amount
$0
No payment methods available
I want a tax receipt.
SIREN
Forme juridique
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Comments
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Confirm
Organization's registration number:
10758 8477 RR0001
Time remaining in your session:
15
Time remaining in your session:
15