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: ______________________________
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.
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 (email@example.com) or
Chris Cammarene-Wessel at 919-515-7678 (firstname.lastname@example.org).