Please complete, print & mail the form I (We) would like to support the --Select the SIUC Program You Wish to Support-- Unrestricted Gift General Scholarships Agricultural Sciences Applied Sciences and Arts Athletics Business and Administration Education and Human Services Engineering School of Law Liberal Arts Library Affairs Mass Communication and Media Arts School of Medicine Public Policy Institute Science Student Affairs and Enrollment by pledging $ --Select the SIUC Program You Wish to Support-- Unrestricted Gift General Scholarships Agricultural Sciences Applied Sciences and Arts Athletics Business and Administration Education and Human Services Engineering School of Law Liberal Arts Library Affairs Mass Communication and Media Arts School of Medicine Public Policy Institute Science Student Affairs and Enrollment by pledging $ by pledging $ through the SIU Foundation.   Joint Gift Yes  No       Spouse Name     First Name Middle Name Last Name   I (We) would like to donate my entire gift immediately.   I (We) would like to make my gift over a specific time period (no longer than 5 years).   Installments shall be in increments of $ , beginning on for an     Annual, semi-annual, quarterly, or monthly basis.   Payment can be in the form of:   Check payable to "SIU Foundation"      Securities (Stocks and Bonds)   Electronic Funds Transfer (directly transferred from your checking account)   Credit Card:     Master Card Visa Discover   Credit Card #   Exp.Date    Signature of Donor  ____________________________________ ------------------------------------------------------------------------------------------------------------------------    (employee name) - gift will be matched by employer(s) listed below with an anticipated match of $which is in addition to my(our) pledge.   Name of Companies/Foundations   Business Employer   Job Title/Position   Business Address   Business Phone Number   Announcements of this gift, including amount and description of contributions and pertinent details, may be made in the usual Southern Illinois University, SIU Foundation and University related publications provided for this purpose.   Date   Donor(s) Name   Home Address 1   Home Address 2   City    State    Zip      Home Phone Number    E-mail      Has Your Address Changed Recently ? Yes  No   Please mail check and/or completed form to, Southern Illinois University Foundation, Mail Code 6805, Carbondale, IL 62901 OR for gifts to the School of Medicine, Mail Code 9666, Springfield, IL 62794. Thank you for your support ! Official Use   $ WEB Y6PWF1     DS   $ WEB Y6PWF1     DS   $ WEB Y6PWF1     DS