NHCA Care PAC Contribution Form - Nebraska Health Care Association

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NHCA Care PAC Contribution Form - 2021

Step 1 of 4

25%

Contributor Information
Recognition Name*
First Last
Facility/Company Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*

Contribution Information
Contribution Recognition*
- Recognize as Individual Contribution
- Recognize as Facility Contribution
Please note:
If you are an individual, you can choose a Club Membership based on your contribution level. This is available to member facility employees, corporate office staff, owners, as well as individual members. Proprietary member facilities can participate at a suggested $2 per bed or more. Non-profit or government facilities should consult with a tax professional prior to contributing.
Do you want to donate as a proprietary member facility using a per bed contribution?*
- Yes
- No
Proprietary Member Facility Per Bed Contribution
How much would you like to contribute per bed?*
Contribution suggested at least $2 per bed.
Number of Beds*
Please enter a number greater than or equal to 1.
Total Proprietary Member Facility Per Bed Contribution
$0.00
Member Facility/Company Contribution
Member Facility/Company Contribution Amount*
Total Member Facility/Company Contribution
$0.00
Individual Contribution
Individual Contribution Amount*
Total Contribution Amount
$0.00
Contribution
Your Contribution Level is:
Contributor Club
Your Contribution Level is:
Leadership Club
Your Contribution Level is:
Advocate Club
Your Contribution Level is:
Capitol Club
Your Contribution Level is:
Silver President’s Circle
Your Contribution Level is:
Gold President’s Circle
Your Contribution Level is:
Platinum President’s Circle
Contribution Levels
President’s Circle
● Platinum President’s Circle $5,000 or more
● Gold President’s Circle $2,500-$4,999
● Silver President’s Circle $1,000-$2,499
Capitol Club $500-$999
Advocate Club $200-$499
Leadership Club $50-$199
Contributor Club $10-$49
Contributor Category*
Please select the contributor category that best describes you.
- Facility Administrator & Team Members
- Corporate Office Team Member
- Business Partner/Vendor
- Facility / Building / Group Contributor
- Other
Contribution Level
- Platinum President’s Circle
- Gold President’s Circle
- Silver President’s Circle
- Capitol Club
- Advocate Club
- Leadership Club
- Contributor Club

Payment Information
Total Contribution Amount
$0.00
Care PAC Goal
Payment Type*
- I will pay with a Credit Card
- I will pay by mailing a check
For recurring donations, please contact NHCA at 402-435-3551.
Credit Card Information
Cardholder Name
Cardholder's Email*
The Cardholder address the same as the previous address in this form?
- Yes
Cardholder Address*
Street Address Address Line 2 City State ZIP Code
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

Review Your Selections
Click "Previous" to make changes. Click "Submit" to process your registration(s). {all_fields} After clicking on "Submit", please wait. It could take a bit to process. You will be redirected to a new screen when the transaction has been completed.

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