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:____________________