Carmen R. "Carm" Parkhurst Poultry Science
Teaching Program Endowment
NC State University College of Agriculture and Life Sciences
Printable Bank Draft Form
Please Type or Print Clearly
Full Name: _________________________________________
Social Security #: _____________________________
Job Title: ___________________________________________
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.
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 (email@example.com) or Chris Cammarene-Wessel at 919-515-7678 (firstname.lastname@example.org).