Bridge Grant Contribution Commitment Form

Name (Please type or print)__________________________________________________________

Address:_________________________________________________________________________

City/State/Zip_____________________________________________________________________

Phone Number:______________________________     Email:______________________________        

 FORMCHECKBOX  Alumna/us (Class Year________)   FORMCHECKBOX  Faculty    FORMCHECKBOX  Staff     FORMCHECKBOX  Friend

TOTAL PLEDGE AMOUNT:___________________________

DESIGNATION OF CONTRIBUTION

_________ Bridge Grants

METHOD OF GIVING   All annual pledges are due by June 30^th

 FORMCHECKBOX  Payroll Deduction (TSU employees only)

      Please deduct  $___________ per month  from my TSU payroll

      Start deductions on ___________ (Month/YR)

                FORMCHECKBOX  Stop deductions when total pledge amount is fulfilled.

                FORMCHECKBOX  Continue monthly deductions until advised in writing to stop. (at least a 30 day notice required)

      Employee#____________ Department ____________________________       

      Signature (Required):_______________________________________    Date:________________

 FORMCHECKBOX  Check Enclosed  (Make check payable to Tennessee State University Foundation)

 FORMCHECKBOX  Credit Card   ____ Visa    _____ MasterCard

      Credit Card # ___________________________________       Expiration Date _____/________

      Name as it appears on credit card_________________________________________________

       FORMCHECKBOX   Charge $_________ to my account one time

       FORMCHECKBOX   Charge $_________ to my account each month beginning _____(Month/YR) until pledge amount fulfilled.

              (Monthly recurring credit card payments will be taken out on or about the 5^th of each the month)

      Signature:____________________________________     Date:____________

 FORMCHECKBOX  Electronic Funds Transfer (Please include a voided check for the account)

      Deduct  $_________ per month from my checking or savings account

      Transmit deductions on (Select One):      FORMCHECKBOX  5^th of the month OR FORMCHECKBOX  20^th of the month 

      Start deductions on:    __________ (Month/YR)

                FORMCHECKBOX   Stop deductions when total pledge amount is fulfilled.             

          FORMCHECKBOX   Continue monthly deduction until advised in writing to stop. (at least a 30 day notice is required)

      Signature (Required):______________________________________      Date:_______________

For Bridge Grant donations only, please return this form to:

Tennessee State University Foundation, First Floor, Goodwill Manor, Nashville, TN   37209-1561; OR

You can make your gift on-line at www.tnstate.edu/contributions and select “Other” for the designation.  You may also drop a check off at the TSU Foundation, located in Goodwill Manor, or call the TSU Foundation at (615) 963-5481 to make a gift by phone; OR.                                                 

Deliver a check to the Office of the president, Tennessee State University, Suite 210, McWherter Administration Building

If you have any questions, please contact the Office of Development at (615) 963-5481.