I/We wish to contribute to the Dr. Judy Mock Internship Fund!

Gift Intention Form

My/Our Total Gift Amount Will Be: $___________.

__ This is a corporate gift.  Company name_______________________________________________________________________________

__ A check for the total amount of $_______ is enclosed.

__ I would like to charge my entire gift amount.  Card Type: __American Express  __Discover  __Mastercard  __Visa
Name on Card:_____________________________Expiration Date:________
Card Number:________________________Signature__________________________

__ A check for $________ as my first payment is enclosed.  A balance of $________ remains on my pledge and will be paid in equal annual installments over the next ___ (1-5) years.

__ I am enclosing a completed Payroll Deduction/Bank Draft Authorization Form.  Each month for the next ___ (1-5) year(s) $_______($10 min.) will be deducted.

__ I am interested in learning about ways of supporting the Department of Family and Consumer Sciences and NC Cooperative Extension Service.  Please call me.

(Please print or type.) Name________________________________________________________________
Phone_________________(Day) _________________(Eve.) FAX________________ Email_________________________ Website:________________________________
Addresses (office/home)_________________________________________________
Employer (many match gifts!)______________________________________________

Please make checks payable to The North Carolina Agricultural Foundation
(you will receive an official receipt for your contribution,
and pledge reminders if you have chosen that option).
Send to: NC Agricultural Foundation, NC State University Box 7645, Raleigh, NC 27695.
Or, you may fax your forms to 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).

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 Last modified:  May 2003