I accept the invitation to help the victims of Hurricane Floyd
Floyd Relief
NC State University College of Agriculture and Life Sciences

Bank Draft Form

Please Type or Print Clearly

Full Name: __________________________________________ Social Security #: _____________________________

Job Title: ___________________________________________ Department:___________________________________

Work Address: ______________________________________ Home Address: ________________________________

__________________________________________________ _____________________________________________
 

Work Phone: ________________________________________ Home Phone: __________________________________
 

Financial Institution: __________________________________ Account Number: ______________________________



                                                                                                               Advance Acct. #____________
for office use only :  ID#________________ Address Change? _____   Advance Acct. #____________
                                                                                                               Advance Acct.#_____________

I wish to make the following contribution. I understand that the total designated amount will be deducted from my account each month for a period of ____ years (1-2). My total contribution amount will be $____________.

Please indicate below how much per month you wish to be deducted from your account toward the following funds
(amount deducted per month must be greater than $10 for each fund designated):

_____ Please designate $____ per month to support the CALS Floyd Relief Fund (100% of these funds will   directly benefit Eastern North Carolina families and communities impacted by Hurricane Floyd).
______ Please designate $____ per month to support the NCCESF Benevolence Fund (100 % these funds will directly benefit Extension families impacted by Hurricane Floyd).
______ Please designate $____ per month to support the NCDA Farmer Disaster Fund (100% of these funds will directly benefit agriculture and farm families impacted by Hurrican Floyd.)

Bank Draft Forms must be received by the third business day of the month in which you wish the form to be effective.

Signature:_______________________________________________ Date:____________________

PLEASE ATTACH A PREPRINTED CHECKING OR SAVINGS ACCOUNT DEPOSIT SLIP, OR A CHECK ON WHICH YOU HAVE WRITTEN “VOID.”  THE PREPRINTED INFORMATION MUST INCLUDE
THE FINANCIAL INSTITUTION’S BANK NUMBER AND YOUR ACCOUNT NUMBER.
YOUR BANK DRAFT PLEDGE CANNOT BE COMPLETED WITHOUT THIS INFORMATION.

Please return completed Bank Draft Form with your completed Gift Intention Form to:
NC Agricultural Foundation (Tax ID #56-6049304), NCSU Box 7645, Raleigh, NC 27695-7645.
If you have questions or require more information, please call
Sandy Zaslow at 919-515-2781 (sandra_zaslow@ncsu.edu) or
Chris Cammarene-Wessel at 919-515-7678 (ccwessel@ncsu.edu).