KENTUCKY STATE UNIVERSITY
Employee Donation Form
Amount per pay period $_____
Number of pay periods _____
Date of first deduction _____
Received on _____
Received by _____
Employment Category: Faculty Adjunct Faculty Full-Time Staff Part-Time Staff
Name___ KSU ID #___
Address ___ City ___ State ___ Zip ___
Email _____ Phone _____
Department _____ Campus Phone _____
Check if you would like to be listed as "anonymous" in all donor recognition materials.
I pledge a gift of $
to Kentucky State University. Total will be divided by _____ pay periods (max 26).
I authorize these deductions to be made from my paycheck until I change these arrangements in writing (please allow 30 days) or I am no longer employed by Kentucky State University.
| Gift Per Pay Period | Total Gift for Year |
|---|
| $72.54 | $1,886 |
| $38.46 | $1,000 |
| $19.23 | $500 |
| $9.62 | $250 |
| $3.85 | $100 |
| $1.92 | $50 |
Amount: $_____
Payment options:
☐ Cash
Check (payable to Kentucky State University)
Payroll Deduction
Credit Card: Visa
Master Card
□ Discover
American Express
Card #:_____
Exp. Date: ___
Security Code: ___
<div style="text-align: center;"><img src="imgs/img_in_image_box_0_1_1123_85.jpg" alt="Image" width="99%" /></div>
Designate my contribution to:
Where the need is the greatest
□ Where the need is the greatest
Unrestricted Scholarship Fund
Other ___
SIGNATURE: ___ DATE: ___
Please return this completed form to the Office of Institutional Advancement
Kentucky State University | 400 East Main Street Hume Hall Suite 202 | Frankfort, KY 40601
advancement@kysu.edu | 502-597-5500