Annual Fund Faculty/Staff Payroll Deduction Form

*= TOTAL amount

*Amount from each paycheck:

*How many paychecks do you want the above amount deducted?

*NAME:

*HOME ADDRESS:

*CITY:

*STATE:

*ZIP CODE:

TELEPHONE #:

*GOTHIC ID:

*EMAIL ADDRESS:

By hitting FINISH and submitting this form to the Office of Development and the Payroll Office, I am authorizing deductions to be taken from my pay checks as indicated above.

Hard copies of this form are available by calling Lori Summers at (201) 200-3489, or emailing her at lsummers@njcu.edu.