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| Temple University School of Medicine |
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Faculty & Staff Campaign Please print this form and once completed, mail to: Faculty/Staff Campaign Office of Development & Alumni Affairs Old Dental School Building 3223 North Broad Street, Suite 413 Philadelphia, PA 19140 Faculty/Staff Pledge Form (B0663) My pledge is $______________ and is payable as follows: My check payable to Temple School of Medicine in the amount of $ ____________ is enclosed. My pledge via payroll deduction will be paid in installments of $__________ starting ________. (Pease indicate preferred start date) I am making my gift via credit card. Credit Card Type__________________ Credit Card #__________________________________________ Expiration Date____________ 3-4 digit card verification number# _____________________________ Name as it appears on Credit Card__________________________ Signature________________________ ****PLEASE COMPLETE OR CORRECT ALL INFORMATION BELOW**** Name__________________________________ TUID (found on your Temple ID card)_____________________ Department/Title________________________________________________________________________________ Home Address__________________________________________________________________________________ City___________________________State_______________Home Phone________________________________ Campus Phone_______________________Email Address_____________________________________ __________________________ Signature(s) Date
*Gifts may be made by
check, Visa, American Express, MasterCard, Discover or through gifts of
securities. Gifts of appreciated securities may be deducted at full market
value on the date of transfer to Temple, and if the donor has owned them for
at least 12 months, they will not be subject to tax on appreciated
value. If you have questions about such a transfer, please call the
Development Office at (215) 707-4868. The chart below illustrates how
making a monthly contribution can have a major impact. |
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