Please Type or Print Clearly

Full Name: _________________________________________

Social Security #: _____________________________

Job Title: ___________________________________________

Department:___________________________________

Work Address: ______________________________________
                       ______________________________________

Home Address: ________________________________

                       ______________________________________

Work Phone: ________________________________________

Home Phone: _________________________________

Financial Institution: ___________________________________

Account Number: ______________________________
 

for office use only : ID#_________________   Org Code 936-AG    Advance Acct. #_________    Tech Code 6

I wish to make the following contribution in support of the Carmen R. "Carm" Parkhurst Poultry Science Teaching Program Endowment. I understand that the total designated amount will be deducted from my account each month for a period of ____ years (1-5). My total contribution amount will be $____________.

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

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

Signature:_______________________________________________

Date:____________________
 

PLEASE ATTACH A PREPRINTED CHECKING OR SAVINGS ACCOUNT DEPOSIT SLIP, OR A CHECK ON WHICH YOU HAVE WRITTEN “VOID.”  THE PREPRINTED INFORMATION MUST INCLUDE
THE FINANCIAL INSTITUTION’S BANK NUMBER AND YOUR ACCOUNT NUMBER.
YOUR BANK DRAFT PLEDGE CANNOT BE COMPLETED WITHOUT THIS INFORMATION.
 
 

Please return completed Bank Draft Form with your completed Gift Intention Form to:

NC Agricultural Foundation (Tax ID #56-6049304), NCSU Box 7645, Raleigh, NC 27695-7645.

(FAX: 919-515-5274) If you have questions or require more information, please call Gerald Havenstein at 919-515-5555 (gerald_havenstein@ncsu.edu) or Chris Cammarene-Wessel at 919-515-7678 (chris_wessel@ncsu.edu).