PAYROLL DEDUCTION FORM
You are encouraged to make your gift in the form of a pledge
(Please print)
Name: _____________________________________________________________
Address: ____________________________________________________________
City: __________________________ State: _________ Zip Code: _________
Telephone: ____________________________
Signature: ___________________________________ Date: _________________
I/we pledge: $__________ over a period of _____ pay periods, or until I request it be discontinued.
Enclosed: $_________ Remainder $ ________ to be paid as follows:
Please indicate method of payment:
Payroll deduction of $__________ per month (Banner ID# _ _ _ _ _ _ _ _)
Payroll deduction of $__________ per quarter (Banner ID# _ _ _ _ _ _ _ _)
Payroll deduction of $__________ annually (Banner ID# _ _ _ _ _ _ _ _)
Please use this gift for one of the following:
Where the need is greatest
Book Scholarships
Complete College Scholarships College Ready Disadvantaged/at-risk
Innovation Fund
Faculty and Professional Staff Development
Other ___________________________________
Please make your gift payable to Southwest Foundation.
Your gift is tax deductible to the extent of the law.
0111185NEW12115 - Southwest Tennessee Community College is an AA/EEO employer and does not discriminate on the basis of
race, color, national origin, sex, disability or age in its program and activities. The following person has been designated to handle
inquiries regarding the non-discrimination policies: Executive Director of Human Resources and Affirmative Action, 737 Union
Avenue, Memphis, TN 38103, (901) 333-5760.
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