Employer Name First Name Options - Select One - None -Payroll Deduction Check Cash Credit Card or ACH My Contact Information Last Name Amount Per Pay Period Home Address Location/Department Name Preferred Donation Method Frequency you are Paid - None -Weekly (52 times/yr) Bi-Weekly (26 times/yr) Semi-Monthly (24 times/yr) Other City Employer Employee Number If other, what frequency: State - Select -Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Amount of Check Donor Notes Zip Code Amount of Cash Email Address Office Phone Cell Phone Note Submit
