I accept the invitation to help establish the
Allen Beals-Herman Sampson Agricultural Institute Scholarship Endowment

Gift Intention Form


__ This is a corporate gift.  Company Name_______________________________________________________________________________________

__ A check for the total amount of $_______ is enclosed.

__ I would like to charge my entire gift.
Card Type: __American Express  __Discover  __Mastercard  __Visa
Card Number: _______________________________
Expiration Date: ____________________________
Name on Card: ______________________________
Signature: __________________________________

__ A check for $________ as my first payment is enclosed.  A balance of $________ remains on my pledge and will be paid in equal annual installments over the next ___ (1-5) years.

__ I have completed a Bank Draft/Payroll Deduction Form.  Each month for the next ___ (1-5) year(s) $_______ ($10 minimum) will be deducted.

__ This gift is designated for: ___the endowment,  ___annual award(s) OR $_____/$_____split (endowment/annual).

(Print) Name____________________________________________________________________________
Phone____________________(Day) ___________________(Eve.)
FAX_____________________ Email__________________________ Website___________________________________________
Employer (many match gifts to NC State!) ________________________________________________________

Please make checks payable to The North Carolina Agricultural Foundation.
You will receive an official receipt for your contribution and reminders if you have made a pledge.
Send to: NC Agricultural Foundation, NCSU Box 7645, Raleigh, NC 27695.
 If you have questions or need more information, please call John Cornwell at (919)515-3248 (Ag_Institute@ncsu.edu).
or Chris Wessel at 919-515-7678 (chris_wessel@ncsu.edu).

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 Last modified:  June 2003