I accept the invitation to help the victims of Hurricane Floyd
Floyd Relief
NC State University
College of Agriculture and Life Sciences
Faculty and Staff Payroll Deduction Form

Please Type or Print Clearly

Full Name: __________________________________________ Social Security #: _____________________________

Job Title: ___________________________________________ Department:__________________________________

Campus Address: _____________________________________ Home Address: _________________________________

__________________ ______________________________       ___________________________________________

Campus Phone:____________________________________  Home Phone:____________________________________

Pay Period: Bi-weekly _____ Monthly _____


                                                                                            Advance Acct. #_________
for office use only : ID#_____________Org Code 936-AG Advance Acct. #_________ Tech Code 6
                                                                                            Advance Acct. #_________

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

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

I authorize the University Payroll Office to deduct the amount(s) indicated above from my pay each month for a period of _____ year(s) (1-2). My total pledge is $________. (A completed pledge form is attached.)

I understand that I may amend or cancel this authorization by written notice to the University Payroll Office (changes received after the tenth of a month will be effective the next month).

Signature:__________________________________________ Date:____________________



Please return with your completed Pledge Intention Form to:
Floyd Relief Drive, c/o NC Agricultural Foundation,  Box 7645, Raleigh, NC 27695-7645 or FAX to 919-515-5274.
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).

THANK YOU!