Campaign Pledge Form 2011

For credit card charges, must be your billing address.

I have been contributing to the United Way for ___ years. Register me for the Loyal Contributor program!

Want to see how your contribution is making a difference? Please provide your home email address so we can show you how, and provide opportunities to give, advocate, and volunteer all year long.

If you selected Bill Me, please note what amount you are giving.

If you selected Automatic Cash Withdrawal, please note the amount that you are donating and what frequency you would like the amount to be removed from your account. We also need your checking account routing number.

If you selected Credit Card, please include what amount you are donating, your card number, cvs number and expiration date.

If you selected United Way Program or local Agency, Please specify which program or which agency you would like to contribute to.

If you are donating $500 or more, you qualify for our Leadership Circle! Please note whether you would like your name to appear as above, as something different, or whether you would like to donate anonymously.

By submitting this form, I verify that the enclosed information is complete and accurate.