Advancement - Payroll pledge form

Name: Name: Title First Last Suffix
Banner ID:
Position/Title:
Office #:
Extension #:
Preferred email:
Preferred Telephone: Preferred Telephone: - ### - ### ####
Home Address: Home Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please designate my gift to:

Please designate my gift to: Scholarships (Future Leaders Scholarship Endowment) Bursaries Varsity student-athletes (Adopt-A-Ridgeback) Where most needed Other
Preferred faculty:
Please specify:
Please specify existing named fund:
Please designate my gift to:

Please designate my gift to: Student Relief Fund Brave The Future campaign Future Leaders Scholarship Endowment Other Other
Please designate my Pi Day gift to:

Please designate my Pi Day gift to: Highest priority Faculty of Business and Information Technology Faculty of Education Faculty of Energy Systems and Nuclear Science Faculty of Engineering and Applied Science Faculty of Health Sciences Faculty of Science Faculty of Social Science and Humanities School of Graduate and Postdoctoral Studies Athletics
Please select the option that matches your gift intentions for the payroll deduction:

Please select the option that matches your gift intentions for the payroll deduction: I will make a five-year pledge with a pre-determined amount per payment. I will make continuing contributions with a pre-determined amount per payment until otherwise advised. Or, I will make a specific contribution with a pre-determined total amount and period of contribution.
Per pay contribution:

Per pay contribution: $100 $50 $25 Other Other
Total contribution of:

Total contribution of: $1,000 $500 $200 $100 Other Other
Number of payments:
I am paid:

I am paid: Bi-weekly Monthly
Payment start date:
Donor recognition:

Donor recognition: I would like my name to appear in public donor listings. I would like to remain anonymous.
My name should appear in public donor listings as:
This gift is in honour of:
I would like the Advancement Office to send a note to the honoree acknowledging my donation.

I would like the Advancement Office to send a note to the honoree acknowledging my donation. Yes No
Honoree's address: Honoree's address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
I would like to be contacted by the Advancement Office to obtain further information.

I would like to be contacted by the Advancement Office to obtain further information. Yes
I would like to be contacted by the Advancement office to obtain further information.

I would like to be contacted by the Advancement office to obtain further information. Yes
Gifts made by payroll deduction will be reported in box 46 of your T4 form; no charitable receipt will be issued.

Advancement Office

2000 Simcoe Street North, Oshawa, Ontario L1G 0C5

905.721.8668, ext. 5645 Email: donations@ontariotechu.ca

Charitable registration number: 85924 8049 RR0001

Advancement - Payroll pledge form

Advancement - Payroll pledge form

Gifts made by payroll deduction will be reported in box 46 of your T4 form; no charitable receipt will be issued.