USI Foundation

Payroll Deduction Pledge Notification Form.

If you are a university employee and would like to support a fund through payroll deductions, please fill out this notification form to alert the Foundation Office of your intentions.

THIS FORM IS NOT A PAYROLL DEDUCTION FORM.

THE FOUNDATION OFFICE WILL CONTACT YOU TO COMPLETE THE REQUIRED CONTRACT BEFORE ANY FUNDS ARE DEDUCTED FROM YOUR PAY.

Name:
USI phone extension:
School/Department:
Pay schedule:	MonthlyBiweekly

Fund(s) you wish to support: (check as many as apply)
$	USI Annual Fund - where the need is greatest
$	Deans Scholarships
$	Friends of David L. Rice Library
$	Friends of New Harmony Theatre
$	Historic New Harmony Society
$	Historic Southern Indiana
$	New Harmony Gallery of Contemporary Art
$	Presidential Scholarships
$	College of Business
$	College of Education & Human Services
$	College of Liberal Arts
$	College of Nursing & Health Professions
$	College of Science & Engineering
$	Varsity Club
$	Society for Arts & Humanities
$	IT Alliance Scholarship
$	Other (Please specify):

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