Announcing the Creation of the

Carmen R. "Carm" Parkhurst Poultry Science Teaching Program Endowment

NC State University College of Agriculture and Life Sciences

Printable Faculty, Agent, Specialist and Staff Payroll Deduction Form

Please Type or Print Clearly

Full Name: __________________________________________

Human Resources ID #: _____________________________

Job Title: ___________________________________________

Department: ________________________________

Campus Address: ___________________________________

                         ___________________________________

Home Address: ________________________________

                        ___________________________________

Campus Phone: _____________________________________

Home Phone: _________________________________

Pay Period: Bi-weekly _____ Monthly _____
 
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 pay each month.

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

I authorize the University Payroll Office to deduct the amount indicated above from my pay each month for a period of _____ year(s) (up to five). My total pledge is $________. (A completed gift intention form is attached.)

I understand that I may amend or cancel this authorization by written notice to the University Payroll Office (changes received after the tenth of a month will be effective the next month).

I understand that this payroll deduction authorization is in support of the Carmen R. "Carm" Parkhurst Poultry Science Teaching Program Endowment.
 

Signature:_______________________________________________

Date:____________________


Please return with your completed Gift Intention Form to:
NC Agricultural Foundation, NCSU Box 7645, Raleigh, NC 27695-7645.
Or, you may fax your forms to 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).
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Last modified: October 2001
cals_foundation@ncsu.edu