Southwest Georgia Medical Student Housing Complex Gift Pledge
Please Print:
Your gift wil be used
to support the following:
Your Name
- 80 %: Southwest Georgia Medical
Campus Housing Complex Campaign
Email
- 7 %: Employee Aid
Employee I.D. Number
- 3 %: Disaster Aid
- 10 %: The United Way of
Southwest Georgia
Extension
Department
Signature
Thank you!
Date
Amount Pledged:
_____$4.00 per pay period ($104 annually)
 Vacuum Tumbler
 Cooler
OR
_____$7.00 per pay period ($182 annually)
 Chair
 Bag (reversible)
OR
_____$10.00 per pay period ($260 annually)
 Polo Style Shirt
OR  Slate Color Scrub Top
Style: ___Women’s
Size (circle one) S M L XL 2X 3X
___Men’s
Size (cirlce one) S M L XL 2X 3X 4X 5X
Color: ___lime ___peach
Style: ___Women’s
___Men’s
Size (cirlce one):
S M L XL 2X 3X 4X 5X
AND
OR
 Vacuum Tumbler
 Cooler
_____$20.00 per pay period ($520 annually)
 Jacket
Style: ___Women’s
Size (circle one) S M L XL 2X
___Men’s
Size (cirlce one) S M L XL 2X 3X
 Duffle Bag
OR
AND
OR
 Vacuum Tumbler
 Cooler
_____ $40.00 per pay period ($1,040 annually)
Wendell August valet box
AND
Choice of one other item:
 Vacuum Tumbler
 Cooler
 Chair
 Bag (reversible)
 Polo Shirt (circle one):
Women’s: S M L XL 2X 3X
Men’s: S M L XL 2X 3X 4X 5X
Color: ___lime
___peach
 Slate Color Scrub Top (circle one):
Style: ___ Men’s
___ Women’s
S M L XL 2X 3X 4X 5X
 Jacket (circle one):
Women’s: S M L XL 2X
Men’s: S M L XL 2X 3X
 Duffle Bag
_____Other ($1.00 or more) $___________(write in Amount)
_____I decline the gift item(s)
For office use only:
_____ recieved gift
_____ wearable item ordered
_____ payroll notified
P.E.A.C.H. patrol number