UNC School of Medicine

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The Medical Foundation of North Carolina, Inc.

AUTHORIZATION AGREEMENT FOR ELECTRONIC GIFT PAYMENTS

Please print and complete this form, sign it, and mail it to:
The Medical Foundation of NC
880 Martin Luther King Jr. Blvd.
Chapel Hill, NC 27514

If you have questions, please call 800-962-2543.

You may expect your gift deductions to begin within 30-45 days after this authorization has been processed and they will take place on or about the 10th day of each month. Your monthly bank statement will itemize this draft when it occurs. Gift receipt(s) will be issued from each area to which you have designated your gift.

Thank you for your generosity!

BIOGRAPHICAL INFORMATION

Your name

Home address

City

State

Zip*

Home phone

(please include area code)

Work phone

The best way to reach me is by: Email US Mail Telephone

BANK INFORMATION

I/We authorize the Medical Foundation of NC to initiate debit entries to my/our bank account established at the financial institution indicated below:

Financial institution

Address/Branch office

City and state

Transit/ABA number

Account number

Type of account

Checking Savings

(YOU MUST ATTACH A VOIDED CHECK OR DEPOSIT SLIP)

GIFT DESIGNATION

I/We wish to make monthly gift payments of $ posting to my/our account.

For a period of:

6 months 12 months 24 months
36 months Until I request that you stop

For recognition in various Gift Clubs, the Medical Foundation of NC operates on a fiscal year running from July 1 to June 30. Each monthly gift payment will be recognized in the fiscal year in which it is received.

Please direct this monthly gift to the following areas in these proportions:

$ Allied Health Sciences
$ Bowles Center for Alcohol Studies
$ Carolina Cardiovascular Biology Center
$ Carolina Vaccine Institute
$ Center for Maternal and Child Health
$ Center for Women's Health Research
$ Childhood Trust
$ Cystic Fibrosis/Pulmonary Research & Treatment Center
$ Department of Anesthesiology
$ Department of Biochemistry and Biophysics
$ Department of Family Medicine
$ Department of Neurology
$ Department of Social Medicine
$ Department of Ophthalmology
$ Department of Orthopaedics
$ Department of Otolaryngology/Head and Neck Surgery
$ Department of Pathology and Laboratory Medicine
$ Department of Physical Medicine
$ Department of Psychiatry

$	•	Ham Society Fund
$	•	UNC Eating Disorders Program

$ Department of Radiology
$ Department of Surgery
$ Diabetes Care Center
$ Division of Cardiology
$ Excellence Fund (Non-Alumni Giving)
$ Family Support Network of North Carolina
$ Gene Therapy Center
$ Lineberger Comprehensive Cancer Center
$ Loyalty Fund (Alumni Giving)
$ North Carolina Children’s Heart Center
$ North Carolina Children’s Hospital
$ North Carolina Jaycee Burn Center
$ North Carolina Women’s Hospital
$ Neuroscience Center
$ Program on Digestive Health
$ Program on Integrative Medicine
$ Speech and Hearing Advancement Fund
$ Student Health Action Coalition (SHAC)
$ Thurston Arthritis Research Center
$ UNC Hospice
$ UNC Kidney Center
$ UNC Center for Functional GI and Motility Disorders
$ Smoke Free Families
$ Other If other, for what purpose?

$ Total Contribution

ACCREDITATION

How would you like your name listed in publications?

I wish this gift to be credited anonymously.

I wish this gift to be credited jointly with my spouse.

Spouses Name

This gift is a payment on a pledge.

This gift is in

honor of
memory of

If you wish this person to be notified of your gift (amount
of gift will not be indicated), please supply their address:

Comments

AUTHORIZATION

This authorization will remain in full force and effect until the Medical Foundation of NC has received written notification from me (or either of us) of its modification or termination in such time and in such manner as to afford the Medical Foundation of NC a reasonable opportunity to act on it.

Signature

Signature, if Joint Account

Please print and complete this form, sign it, and mail it to:
The Medical Foundation of NC
880 Martin Luther King Jr. Blvd.
Chapel Hill, NC 27514

Privacy Statement: Information provided on this online form will be used by the Medical Foundation of NC solely for the purpose of crediting you correctly for your gift. Personal information contained in the Foundation’s records is used only for University-related business and will not be shared with outside parties.