Your Company Make a Choice That Really Matters United Way
EMPLOYEE NAME
 First Name:    Last Name:
 Employee ID #
Social Security Number: Be sure to include the dashes
  Office Phone Number: EX: 999-999-9999 
  E-Mail Address: EX: you@domain.com
GIFT PLEDGES
I pledge a gift of a Percentage of Salary through a payroll deduction.
I pledge a gift of a Hours Pay per pay period through payroll deduction. 
I pledge a Gift Each Pay Period through payroll deduction.
.
I am donating directly through my VISA Card Other Amount (ex: 25.50):
I am donating directly through my Master Card Other Amount (ex: 25.50):
I  am donating directly through my American Express Card Other Amount (ex: 25.50):
I  am donating directly through my Discover Card Other Amount (ex: 25.50):
Credit Card Number:   Do not use spaces or dashes
Expiration Date:   EX: 10/2004
PLEASE DIRECT MY GIFT TO THE FOLLOWING UNITED WAY
(CHOOSE FROM ONE TO THREE UNITED WAYS)
  This column must add up to 100% 
 
PLEASE DIRECT MY GIFT TO THE FOLLOWING SPECIFIC AREA
(CHOOSE FROM ONE TO THREE UNITED WAYS)
  This column must add up to 100% 
PLEASE DIRECT  MY GIFT TO THE FOLLOWING AGENCY:
(FROM ONE TO THREE AGENCIES)
  This column must add up to 100% 
NO SELECTION WILL DESIGNATE YOUR GIFT TO THE
UNITED WAY GENERAL FUND
NOTIFICATIONS:
 I would like to receive periodic newsletters from my United Way
YES  NO 

 

 I would like to receive an acknowledgement from my United Way
YES  NO 

 

PLEASE READ BEFORE YOU SUBMIT THE FORM
I understand a payroll deduction pledge will continue until revoked or modified by me.
Payroll deductions will begin 1/1/01.
Donations of $1,000+ year will be recognized as a member of the leadership giving society

Please enter your name in the space below.  Your name below is as legally binding as your signature.