JUDY MOCK ENDOWMENT
BANK DRAFT/PAYROLL DEDUCTION FORM
Please type or print clearly and
return with completed Gift Intention Form.

Full Name: __________________________________ 

I wish to make the following contribution in support of the Dr. Judy Mock Internship. My total contribution amount will be $____________.

I understand that the total amount designated below will be deducted each month for a period of ____ years (1-5).

$500____  $450____  $400____  $350____  $300____  $250____  $200____  $150____  $100____  $75____  $50____  $25____  $10____ Other $____(must be greater than $10)

Forms must be received by the third business day of the month in which you wish the deduction to be effective.

Signature: __________________________________
Date: __________________

NC State Employees Only (Payroll Deduction):
Human Resources ID #: ___________________________
Job Title: __________________ Phone: _________
Department: ________________________________
Campus Address: ___________________________
Home Address and Phone: ___________________ _____________________________________________
Payroll Frequency: __Bi-Monthly    __Monthly

Non-NC State Employees Only (Bank Draft):
Social Security #: ___________________________
Home Address and Phone: ___________________ _____________________________________________
Financial Institution: ________________________
Account Number: ___________________________
Please enclose a voided check or deposit slip with your account number on it.

FOR OFFICE USE ONLY:

ID #______________    Address Change?____ Account #________________ Tech Code 6



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 Last modified:  October 2004
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