UNM School of Medicine - PAYROLL DEDUCTION AUTHORIZATION

 

UNM School of Medicine - PAYROLL DEDUCTION AUTHORIZATION

UNM School of Medicine - PAYROLL DEDUCTION AUTHORIZATION

Name 

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Home Address 

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City, State & Zip 

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Banner ID

Preferred Email: 

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Payroll Status

Please Choose Bi-Weekly Monthly Other

If you are already making payroll contributions, the contribution on this form is meant to:

Be an additional contribution to the current one.

Change just the amount or designation of the current contribution.

Completely cancel and override the current contribution.

I hereby authorize the UNM Foundation, Inc. to:

Deduct a gift each pay period until I notify you in writing to discontinue deductions, in the amount of:

Deduct a gift each pay period until my total gift is:

Deduct a ONE TIME gift, from my next paycheck in the amount of:

Please direct my gift (can choose more than one fund, please indicate dollar amount for each):

Alumni General Fund-200496

Alumni White Coat Fund-202234

Alumni Endowment Fund-878110

La Tierra Sagrada Society-201241

LTSS Physical Therapy Scholarship Fund-203077

LTSS Physician Assistant Scholarship Fund-203078

LTSS Occupational Therapy Scholarship Fund-203079

Please type signature and date below:

Signature 

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Date 

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