Contribute by Payroll Deduction Personal Information Name: Donor Recognition name: Please print name above as you wish it to appear in donor recognition listings. I prefer that my gift be made anonymously. Address 1: Address 2: City: State: Zip: Phone (Day): Phone Evening: Department: BCM ID: BCM Mail Stop: Classification: Faculty Alumnus Faculty/Alumnus Staff Resident Fellow Student Other Gift Details I would like to support: College Priorities Fund Patient Care Fund Research Fund Education Fund Community Service Fund Please deduct $ per pay period for a total pledge of $. Please deduct $ per pay period until I notify you to terminate or change my deduction. (A minimum of $5.00 per pay period is required.) Do not start payroll deductions before this date: (It may take up to two pay periods for your deductions to begin.) Please deduct $ from my next paycheck for a one-time gift. I am (or my spouse is) a BCM alumnus. Please acknowledge this gift as part of the alumni campaign as well.