members

State Museum Payroll Deduction Form for South Carolina State Employees

Please print out the following membership application, fill out and turn it in to your payroll administrator with your completed COMPTROLLER GENERAL'S OFFICE Employee's Withholding & Deduction Form.
South Carolina Museum Foundation • PO Box 11442 • Columbia SC • 29211-1442

Check (or circle) your prefered category: The second amount listed will be deducted from each pay period.
$35 Individual • $1.46
$45 Dual • $1.86
$60 Family/Grandparent • $2.50
 $80 Premier Best Value! • $3.33		 $150 Charter Collector • $6.25
$250 Director’s Guild • $10.42
$500 Foundation Fellows • $20.83
$1,000 Trustee’s Council • $41.66
Name of the state agengcy you are working for: _____________________

Name of Recipient: Mr. ••••• Mrs. ••••• Ms. ••••• Dr. ••••• other

__________________________________________________________

Phone # ___________________________________________________

Email _____________________________________________________

Address ___________________________________________________

City ________________________________ State__________________

Zip______________________ County __________________________

Second name on membership (Dual members and higher categories):
Mr. ••••• Mrs. ••••• Ms. ••••• Dr. ••••• other

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