Date Processed________ Initials ______ Payroll Deduction: Notification Start Date__________ Initials_____ End Date__________ Initials_____
Monthly Gift Amount $________________ x ____________ months per year = Total Annual Gift Amount $________________________
(Please complete all 4 sections and return form to Bill Pritchard, Vice President for Institutional Advancement.)
Name__________________________________________________________________ Today’s Date_________________________
(Title) (First) (Middle/Maiden) (Last) (Preferred Name)
Home Address_____________________________________________City__________________State________Zip______________
Home Phone__________________________ Preferred Email ________________________________________________________
Wesley Alumnus? ___Yes, Class of ______ Wesley Parent? ___Yes, Student’s Name_____________________________________
Wesley Department_____________________ Position/Title _______________________________Campus Bldg/Rm#____________
Is this a joint gift? ___Yes, Spouse Name _______________________________ Spouse Wesley Alumnus? ___Yes, Class of ______
_____ I would like to commit $_____annually. Gifts of $1,000 or more annually secures your membership in the Wesley Society.
_____ I currently give $______ annually and commit to continue this gift.
_____ I would like to increase my current commitment to $_____ annually.
_____ My spouse works for a matching gift company. I am enclosing a completed form to increase my gift.
_____ Payroll Deduction. My number of annual paychecks =______ Please deduct $__________ from each paycheck. (Round up to
the next cent for multiplied amount to reach desired total in section above. Example: $41.67 x 24 paychecks = $1,000.08)
My signature below gives the Finance Office authority to deduct gift amounts from my paychecks. I understand that my contribution will
begin on the next pay period and will continue as directed until I request it to end or change the amount (increase/decrease).To make any
change, I understand that I must notify the Office of Institutional Advancement in writing fifteen days before the next pay period.
Signature:______________________________________________________________ Date:_________________________
_____ My check for $________is enclosed. (Please make checks payable to Wesley College)
_____ I will make my online gift via credit card (Visa, Mastercard, Discover, AMEX) at Please
circle desired option:
1) Ongoing gift in amount of $________ (set amount continues until request in writing to end) charged
monthly/quarterly/twice a year/annually
2) Annual gift in amount of $________ paid all at once
3) Annual gift in amount of $________ paid in scheduled installments monthly/quarterly/twice a year
_____ I would like to learn more about Planned Giving options.
_____ Wesley Fund (supports scholarships and other critical needs)
_____ Academics Specific Program_____________________
_____ Endowed Scholarship Fund (specify)________________
___W Club (select option below)
__General Athletics OR __ Specific Sport ________
___ Other _________________________________________
Your gift is greatly appreciated and tax deductible to the full extent of the law.
Departmental Use Only (Do not write below this line)
S SECTION 1 My Information
SECTION 2 - My Commitment
SECTION 3 - Method of Payment
SECTION 4 - Please apply my gift to
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