Faculty and Staff Payroll Deduction Form

First Name:

Last Name:

Campus Email:

Campus Phone Ext.:

Department:

Banner ID:

I wish to:

Pay period:

Please indicate the amount you would like deducted each pay period.

For a total gift amount of (if enrolling indefinitely, leave blank):

Annual leadership gifts of $1,917+ — with reduced levels for recent graduates ($1,000 for 10–14 years out, $500 for 5–9 years out, and $100 for 1–4 years out) are recognized by membership in the St. Dominic Society.

I authorize Providence College to withhold the above amount per pay period for a duration of:

This is:

I would like to give to:

Please enter the fund or scholarship name.

If you plan to split your gift between multiple designations, please outline the split below:

If your spouse works for a matching gift company, visit Double Your Donation – Forever A Friar to learn more about increasing your impact. If you anticipate a match, indicate the company below.

Company Name:

Contact Information