Welcome to the {enter company} 2023-2024 United Way of Central Georgia Workplace Campaign! {insert company logo} Your Gift to United Way Matters! And Every Donation Counts! Image Image Image Image WORKPLACE PLEDGE FORM Your Contact Information Your Name First Middle Last Work Email Personal Email Phone Number Your Contact Information Address Address 2 City State GeorgiaAlabamaAlaskaAmerican 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 Company Name Employee ID# Recognition This is a joint gift with my Spouse/Partner (Mark if applies) Name of Spouse/Partner Company of Spouse/Partner List My/Our Name in publication as: Donation Options Donation Method Payroll Deduction Cash Check Credit/Debit Card Stocks or Securities Payroll Deduction Contribution Amount Per Pay Period $50 $25 $20 $10 $5 Other... $ My Pay Period is: Weekly (52 pay periods) Every two weeks (26 pay periods) Twice a month (24 pay periods) Monthly (12 pay periods) Other... Check Donation Amount of Check $ Cash Donation Amount of Cash $ Credit/Debit Card Donation Once you finish this form, you will proceed to the payment form to process your credit/debit card. Be sure to enter the same amount on the payment page as you enter on this form. Select Card Occurence One Time Donation Monthly Recurring Donation Yearly Recurring Donation Amount of One-Time Donation $ Amount of Monthly Recurring Donation $ Amount of Yearly Recurring Donation After completing this form you will be redirected to our payment page where you will be able to process your transaction in a secured environment. Please be sure to enter the same values that you have entered on this form. Thank you! Stocks or Securities Please call 478-621-7798 for more information! Total Annual Contribution TOTAL: $0 Update Caring Club Card Enjoy Special Rewards! By donating $156 ($3 a week) or more annually, you automatically enjoy the rewards of a Caring Club membership. You will receive great discounts on food, entertainment and valuable services. I qualify for the Caring Club Card Designations Choose Where to Make an Impact Community Impact Fund United Way of Central Georgia Programs & Initiatives United Way Program Partners United Way of Central Georgia Programs & Initiatives Brookdale Resource Center/United to End Homelessness Mission United Pink Promise United Read United Community Schools United Birth Through Eight Birth Through Eight Initiatives The Basics First Steps Parents As Teachers Dolly Parton Imagination Library United Way Program Partners Donor Notes Additional Donor Details Mark all that Apply I am a first time donor Loyal Contributor Are you a Leadership Giver? I am interested in being a volunteer How many years have you contributed? Agreement My signature below, confirms my payroll deduction request as stated above. If donating by credit card, place your signature below, and click on proceed to payment page and fill out credit card payment form. Signature (press down and drag your cursor inside the box to sign) Reset Date CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.