Pledge Card

Torchbearers 2005

Name                                                      SSN                                               

Dept                                                      Bldg & Office #                                           

I Pledge (choose one):

Continuous Payroll Deduction:

                                                                                 The continuous payroll deduction option

____   $2 per pay period continuous deductions                  is for 12-month contract only, and will

____   $___ per pay period continuous deductions              continue unless and until you send written

                                                                                 notice to the Development Office to change                                                                                                   deduction amount or designation.    

          Finite Payroll Deduction:

____   one day’s pay (amount calculated by Payroll)

____   two day’s pay (amount calculated by Payroll)            number of payroll deductions: ____

____   other amount  $                  

          Check:

____   $____ paid by check, enclosed

          Credit Card:

____   $                   pledged with credit card:

     ____M/C number:                                        name:                                        exp:           

     ____ VISA  number:                                     name:                                        exp:           

     ____Discover number:                                  name:                                        exp:           

     ____ American Express number                      name:                      exp:           

Designation fund:                                                            

Shirt size (circle one, minimum of $50 pledge to receive t-shirt): S   M     L     XL    2XL    3XL   4XL

Signature                                                                   Date

**Return signed and dated form to University Development, Room 103, Admin. Building**