FOR OFFICE USE ONLY
Date _________________
❑ Foundation
❑ Payroll
❑ Employee
❑ File
https://giving.pstcc.edu
PELLISSIPPI STATE FOUNDATION
INTERNAL CAMPAIGN PLEDGE FORM
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Any gift is greatly needed and sincerely appreciated—thank you!
One hundred percent of your tax-deductible donation goes to the designated account of your choice.
Find out more online: www.pstcc.edu/foundation/internalcampaign
Please print in black or blue ink.
Name (Dr./Mr./Mrs./Ms.)______________________________________________ P number________________________
Office phone ________________________ Office/address ___________________________________________________
Home address ____________________________________________ City ________________________ Zip___________
Signature ________________________________________________ Date______________________________________
My spouse works at a company that matches gifts. Company name_____________________________________________
❑ I am a Pellissippi State alumnus, class of __________.
❑ Please make no changes to my current payroll deduction.
❑ Please make the following changes to my current payroll deduction. __________________________________________
GIVING OPTIONS
This replaces all previous forms
PAYROLL DEDUCTION
OTHER GIFT OPTIONS
Recurring payroll
❑ I hereby give $ ______________ to the Pellissippi State
Foundation by (Select one)
I hereby authorize a payroll deduction of $___________
monthly, beginning _____________ (month/year) and
continuing until further notice.
Monthly payroll
I hereby authorize a payroll deduction of $___________
monthly, beginning _____________ (first month/year)
and ending _______________ (last month/year), for a
maximum contribution of $ _____________.
One-time payroll
In person:
❑ Cash ❑ Check _______________ (number/date)
Payable to the Pellissippi State Foundation
In person or online:
❑ Credit card (Check one):
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NOW YOU CAN
GIVE ONLINE!
https://giving.pstcc.edu
❑ Visa ❑ Mastercard ❑ Discover ❑ American Express
I hereby authorize a payroll deduction of $ __________
to be deducted __________________ (month).
Card number____________________________________
Expiration date__________________________________
Name as it appears on card_________________________
Signature_______________________________________
PLANNED GIVING
❑ I have remembered the Pellissippi State Foundation in my estate plan (will, real estate, life insurance policy, 401K,
403B, IRA, etc.).
❑ I would like to learn more about planned giving and estate planning.
PLEASE SEE REVERSE SIDE FOR DESIGNATION OPTIONS
Name/P# ___________________________________________________________
For more information: www.pstcc.edu/foundation/internalcampaign
DESIGNATION OPTIONS
Indicate the percentage or the dollar amount of your donation that you would like to designate to each fund. Only 38
percent of Pellissippi State’s budget comes from the state. The Greatest Need Fund helps fill the gaps and allows the
College the flexibility to invest in the areas in which support is most needed for student success and access.
I want to designate my donation to the following established fund(s) as indicated below:
*Indicates endowment fund
_____ Academic and Student Enrichment Fund
_____ Administrative Council Scholarship*
_____ Administrative Professional Technology (OST)
_____ Administrative Professional Technology Award (OST)
_____ Adult Student Support Fund
_____ Alumni Scholarship
_____ Anatomy and Physiology Program
_____ Karen Anderson Scholarship
_____ Art Program
_____ Art Scholarship
_____ Bagwell Center for Media and Art
_____ Bill and Sharon Brewer Scholarship
_____ Blount County Campus
_____ Business Administration Department
_____ Business Administration Technology Award
_____ Business and Community Services Division
_____ Cardwell Philosophy Fund*
_____ Child of Support Staff Employee Scholarship
_____ Communication Graphics Technology
_____ Computer Science Technology Award
_____ Culinary Arts Program
_____ Disablity Services*
_____ Division Street Campus
_____ Division Street Campus Scholarship
_____ Early Childhood Education Program
_____ Electrical Engineering Technology
_____ Engineering Technology Awards
_____ English Department
_____ Equipment Fund
_____ Excellence in Teaching Award
_____ Faculty Senate Scholarship
_____ Future Teachers Scholarship
_____ Gene Joyce Visionary Award*
_____ General Endowment Fund*
_____ General Scholarship Fund
_____ Greatest Need Fund
_____ Hardin Valley Campus Garden
_____ History Award
_____ Homeless Student Scholarship
_____ Hospitality Program
_____ Imaginary Gardens Award
_____ Inner-City High School Scholarship*
_____ Innovations Award
_____ Interior Design Technology
_____ Roberto Jiménez Memorial Scholarship
_____ KD Lawson Memorial Scholarship*
_____ Liberal Arts Department
_____ Library Resources Fund
_____ Magnolia Avenue Campus
_____ Magnolia Avenue Scholarship
_____ Management Program
_____ Mathematics Department
_____ Mathematics Scholarship*
_____ Mechanical Engineering Technology (John C. Mauer)
_____ Music Scholarship
_____ Natural and Behavioral Sciences Department
_____ Nursing Program
_____ Nursing Scholarship
_____ Paralegal Studies Award
_____ Pellissippi Pantry
_____ Photography Program
_____ Placement Office Fund
_____ Professional Development Fund
_____ Project GRAD Program
_____ Scholars Today and Tomorrow Scholarship*
_____ Service-Learning Program
_____ Spanish Award
_____ Strawberry Plains Campus
_____ Strawberry Plains Campus Scholarship
_____ Student Affairs Development Fund
_____ Student Emergency Loan Fund
_____ Student Life and Recreation Fund
_____ Sue Carter Memorial Scholarship
_____ Support Staff Scholarship*
_____ Tennessee Small Business Development Center
_____ The Arts at Pellissippi State
_____ Theatre Program
_____ Theatre Scholarship
_____ TnCIS/International Studies
_____ TRiO Program
_____ Valorie Hall Memorial Biology Scholarship*
_____ Video Production Technology
_____ Veteran Support Fund
_____ Veteran Support Fund Endowment*
_____ Web Technology
_____ Jack Wilson International Student Scholarship*
_____ Other fund (Please write in name of fund)
________________________________________________
THANK YOU. PLEASE RETURN THIS FORM TO ANEISA MCDONALD IN THE FOUNDATION OFFICE,
GOINS 210, HARDIN VALLEY CAMPUS. FOR ADDITIONAL INFORMATION, CALL 865.694.6525