Western University - Survey - Monthly Payroll Deduction for Western Faculty & Staff

No one knows Western's strengths - and current needs - like you, our faculty and staff. By supporting the University through payroll deduction, you demonstrate to others the value you place on this institution not just as an employer but as an
important contributor to society.

Faculty and staff give to Western in a variety of ways for unique reasons. Every gift - regardless of size - makes a difference
to the University.

Please note: in each section below an asterisk (*) indicates a required field.

About You

Please provide the following information:

*

Name:

Title	First Required	Middle Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/Prov/Postal

City Required	Prov Required	Postal Code Required

*

Country/Region Required

*

Phone Number: Required

Keep me logged in. What's this?

*

Question - Required - Western Employee Number:

Question - Not Required - In addition to being a Western faculty or staff member, do you have any other relationship to the University? Please check all that apply.

	Alum
	Parent
	Student

Question - Not Required - If you are a Western alumna or alumnus, please indicate your degree and grad year (i.e. BA'78).

Question - Not Required - If you are a parent of a Western student, please provide your daughter's or son's name and current year of study:

(Maximum response 255 chars, approx. 5 rows of text)

Your Western Contact Information

*

Question - Required - Department Name:

(Maximum response 255 chars, approx. 5 rows of text)

*

Question - Required - Room Number & Building:

(Maximum response 255 chars, approx. 5 rows of text)

*

Question - Required - Western Phone Number:

*

Question - Required - Western Email Address:

Your Gift

*

Question - Required - Monthly Gift Amount:

*

Question - Required - Duration of Monthly Gift:

*

Question - Required - Designate my gift as follows:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - I want my gift to remain anonymous.

Yes

No

Question - Not Required - If you have selected 'no' to the question above, please enter your name as you would like it to appear for donor recognition purposes.

(Maximum response 255 chars, approx. 5 rows of text)

Tribute Information

*

Question - Required - Is this gift in honour or memory?

Yes

No

Question - Not Required - Honoree's Name:

Question - Not Required - If you know the contact information of the family or individual you would like notified of this gift, please enter it below:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Message to honoree or family member: