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 _____
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).