A.T. Still University
Faculty and Staff Campaign Response Form

 
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Personal Information
First name:
Last name:

Contact Information: Please provide us with your work e-mail and phone number so we may contact you if we have questions about your gift.

E-mail:
Department:
Work phone:
Hourly Salary

I would like to designate my gift in the following way:

I would like to designate my gift further.
For example, if this gift is being made in honor of someone, in memory of someone, a specific endowment fund, a specific scholarship fund, to a department within a school, or a field of research.

Total Amount of Gift/Pledge: $


I wish to pay by:

Credit Card:

Please charge my gift to:


      Visa
      Mastercard
      Discover
      American
      Express
Credit card number:
Expiration date:
 (mm/yy)
Name as it appears on credit card:

(or)

Payroll Deduction:

We are sorry but if you are adjunct faculty, you may not do payroll deductions at this time.

Total Pledge Amount:
$
Number of months
to deduct payment:
 months
Start Date:
(January suggested)
End Date:

Permission to publish:
Yes, I agree to have my name publicized in all appropriate University publications.

Please type your name as you wish it to appear for donor recognition purposes:

No, I wish to remain anonymous and do not authorize my name to be printed in University publications.

Thank you for your generous support!

Please send me more information on estate gifts.

All gifts are tax deductible to the extent allowed by the law.

For questions about the ATSU Faculty/Staff Campaign, please contact a representative of the ATSU Development Office on your campus.

Kirksville Campus 660.626.2180
Mesa Campus 660.626.2530

Please review your information carefully and verify that all is correct. Once you have done so, please click the Submit button below to make your gift, or click the Reset button to clear the form’s contents.