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