WORKPLACE PLEDGE CARD Preferred Donation Method Payroll Deduction Check Cash Credit Card / Debit Payroll Deduction Contribution Amount Per Pay Period $5 $10 $20 $25 $50 Other… $ Number of Pay Periods for Donation One Time 12 pay periods 24 pay periods 26 pay periods 52 pay periods Other… TOTAL: $0 Update Check Donation Amount of Check $ Cash Donation Amount of Cash $ Credit / Debit Card Donors: Thank you for your support of the United Way. To complete your donation by credit or debit card - please click here. Your Name Title First Middle Last Suffix Your Contact Information Employer Your Email Your Phone Your Address Your City Your State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Your ZIP Code Designations All donations go to the General Fund and assist those in greatest need, unless you indicate otherwise. Please provide details below. Donation Preference General Fund Agency Designation Designation Agency Name and percent of designation is required, please provide details below. Agreement My signature below, confirms my payroll deduction request as stated above. Signature Reset CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. PreviewSubmit Leave this field blank
