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):

Leadership annual gifts at the $1,917+ level ($500+ for alumni 6-10 years after graduation, $100+ for alumni within 5 years of graduation) 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:

My spouse works for a company which will match my gift.

Company Name:

Please send your matching gift form to Gift Processing, Harkins 412 or email it to matchinggifts@providence.edu.

Contact Information