Yes! I/We accept the invitation to support the
Department of Environmental and Molecular Toxicology at NC State University through the Department's Endowment Campaign.

The Ernest Hodgson Toxicology Education Endowment*

Pledge Intention Form

Please type or print clearly.

Total Gift Amount: $_______

Naming Opportunity (from brochure): _________________________

I/We wish to be recognized as follows:

___________________________________________________________________________________

___A check for $_________ as my/our total gift amount is enclosed.

___A check for $_________ is enclosed as my/our first pledge payment. Please send my/our pledge reminder for the next payment on ________________ (date). My/Our pledge will be fulfilled in ___ years (one to five).

___I am an NC State University employee.  I have enclosed a completed Payroll Deduction Form for my pledge.

___I am not an NC State University employee.  I have enclosed a Bank Draft Authorization Form for my pledge.

___Please charge my/our total gift amount to:  ___American Express ___Discover ___Mastercard___Visa

Name on card_______________________________  Number___________________________

Expiration Date_______________ Signature__________________________________________


(Print) Name_____________________________________________________

Company Name (if corporate pledge)_________________________________

Employer (some match gifts to NC State!)____________________________

Phone___________________________(Day) FAX______________________

Email__________________________________________________________

Website________________________________________________________

Address_________________________________________________________

________________________________________________________________

Signature__________________________________________Date__________

*Please make checks payable to the Toxicology Endowment Campaign. Until the $500,000 goal for the Ernest Hodgson Toxicology Education Endowment is reached, funds received for this Campaign will be placed in that fund. When the goal is reached, additional contributions to the Campaign will be placed in appropriate toxicology departmental endowments.
You will receive an official receipt for your tax deductible contribution, and pledge reminders will be mailed to you if you have chosen that option.
Tax ID #56-6049304
Please send to:
NC Agricultural Foundation, NCSU Box 7645,
Raleigh, NC 27695 (fax 919.515.5274).

If you have any questions or require additional information, please call Chris Cammarene-Wessel at 919.515.7678 (chris_wessel@ncsu.edu).

Thank you!

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Last modified: June 2003
cals_foundation@ncsu.edu