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.
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__________________________________________
Company Name (if corporate pledge)_________________________________
Employer (some match gifts to NC State!)____________________________
If you have any questions or require additional information, please call Chris Cammarene-Wessel at 919.515.7678 (firstname.lastname@example.org).
Last modified: June 2003