WORKPLACE PLEDGE CARD Your Name Title First Middle Last Suffix Your Contact Information Company Email Phone Address City 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 ZIP Code Donation Method Preferred Donation Method Payroll Deduction Check Cash Bill Me Credit/Debit Card Payroll Deduction Contribution Amount Per Pay Period $5 $10 $20 $25 $50 Other… $ Number of Pay Periods for Donation 12 pay periods 24 pay periods 26 pay periods 52 pay periods Other… Check Donation Amount of Check $ Cash Donation Amount of Cash $ Bill Me Billing Options One Time Quarterly Amount of One Time Invoice $ Amount of Quarterly Invoice $ Total Annual Contribution TOTAL: $0 Update Designations Choose your Impact Area United Way Community Impact Fund Early Childhood Development Parental Engagement Youth Drug & Alcohol Prevention If you would like to designate your contribution to a United Way other than United Way of the Southern Alleghenies, or to a specific nonprofit or program, please type the name of the organization or program below. Agreement My signature below, confirms my pledge 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. Proceed to Payment Page Submit Leave this field blank
