Details Staff Giving Form QUT Staff Number Faculty/Division Dr Miss Ms Mrs Mr Professor Associate Professor First Name Middle Surname Home Address Suburb State Postcode Home Phone Work Phone Ways to Make a Gift Payroll deduction (Full-time and ongoing academic and professional staff only. Casual staff - please consider the following methods of giving). Effective with next pay period, deduct $_________ per pay period from your pre-tax salary (most tax effective). Please tick here if applicable: I am a new payroll deduction donor. This replaces my present payroll deduction. (This authorisation shall remain in effect until you notify the Development Office that you wish to change or stop the payroll deduction). Cheque / Money order - I am enclosing a cheque/money order payable to QUT for $_________ Credit Card - Please charge my credit card in the amount of $_________ Visa Mastercard American Express Card Number Expiry Date Card Holder’s Name Date / / Signature (Required for credit card or payroll deduction) Areas to Make a Gift Please choose the area(s) you would like to support and enter the portion of your gift that each should receive. Please make sure the individual gift amounts equal your total gift. University’s Priorities Amount Learning Potential Fund (QUT will match the donations dollar for dollar) $ _________. Institute of Health and Biomedical Innovation (IHBI) $ _________. Old Government House $ _________. Other: QUT Endowment (QUT will match the donations dollar for dollar) $ _________. QUT Libraries $ _________. Alumni Development Fund $ _________. Education (Remote practicum bursaries) $ _________. Law Founders Scholarship Endowment $ _________. Other area (please specify): ________________________ $ _________. I would like information about providing for QUT in my Will. I have already provided for QUT in my Will. Please Return the Form Via Fax: 07 3138 1514 OR Internal mail: QUT Staff Giving Program QUT Development Office Level 4, O Block Podium Gardens Point campus OR Call us on 07 3138 9097 to make a donation. OR Donate online: visit www.giving.qut.edu.au Thank you for your support of QUT. Your gift will make a lasting impact on the lives of our students and the quality of QUT’s program.