Payroll Deduction Form Personal InformationName* First Last Banner IDAlso known as B Number CPO Phone Number*Gift InformationPlease designate my gift for:* Berea Fund (Tuition Promise Scholarships) Named Endowed Fund Program or Department If you selected Named Endowed Fund or Program or Department, list below: HiddenI authorize Berea to deduct the requested amount per payroll.I authorize Berea to deduct the following amount per payroll:* $5 $10 $25 $50 I receive checks* Bi-weekly Monthly I am a* 9-month employee 10-month employee 12-month employee Gifts is in Memory or HonorPlease make my gift (optional): In honor of: In memory of: Full name of person that you are making the gift in honor or memory of: Address of Honoree City State / Province / Region ConfirmationBy initialing below, I authorize Berea College to continue my payroll deduction until further notice. I understand that I may discontinue this agreement at any time.* Signature (by typing your name here you are authorizing this agreement)* CommentsNameThis field is for validation purposes and should be left unchanged. Δ You can also make a one-time gift or sign up for an electronic funds transfer rather than payroll deduction.