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Torchbearer Pledge Form

Name                                                                       SSN                                               

Department                                                      Bldg & Office #                                  

Circle one:    Centennial Torchbearer ($100+ annually)            Torchbearer ($50-99 annually)

I pledge (check one):               

Continuous* Payroll Deduction:

                         $2.08 per pay period, continuous deduction for Torchbearer (12-month contract)
                         $4.16 per pay period, continuous deduction for Centennial Torchbearer (12-month contract)
                         $2.78 per pay period, continuous deduction for Torchbearer (9-month contract)
                         $5.50 per pay period, continuous deduction for Centennial Torchbearer (9-month contract)
                         $               per pay period, continuous deduction 

Note: This deduction will continue until you send written notice to the Development Office to change the deduction amount or designation.

Finite Payroll Deduction:

                         other amount $                  over           pay periods

Personal Check:

                         $              paid by check, enclosed

Credit Card:

                         $              pledged with my credit card:

MasterCard          VISA           Discover          American Express       
Account #                                            Expiration Date                       
Name on card                                                                           

                                                                                                    
Signature                                                            Date   


Designated Fund:

I want my gift to go to                                                                     

**Return completed form to University Development, Room 103, Administration Building**           
                 

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