Payroll Deduction Form

To contribute through payroll deduction, complete the form below.
Annual gifts of $1,000 or more ($42/pay period) places one in the Carey Society.

Name Name First Last
School/Department
Campus
Office Phone Office Phone - ### - ### ####
Please select one of the following:

Please select one of the following: I do not have an active payroll deduction. I have an active payroll deduction and this submission will replace it. I have an active payroll deduction and this submission will add to it.
Total amount to be deducted per pay period:
Gift Designation

Gift Designation Use my gift where needed most (unrestricted) I will split my designation below Designate my gift for: Designate my gift for:
Or Split your Designation (enter fund and amount)
Gift Duration

Gift Duration Deduct my gift indefinitely* 3 years (72 pay periods) 2 years (48 pay periods) 1 year (24 pay periods)
By signing below,
I authorize the above contribution to be payroll deducted from my checks in the manner described on this form.

William Carey University does not provide goods or services in whole or partial consideration for any contributions made by payroll deduction.
*I understand that this authorization can be rescinded at any time by notifying the personnel office in writing.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Signed Date Signed / MM / DD YYYY