WORKPLACE PLEDGE CARD - SHATTUCK ST. MARY'S Your Name Title First Middle Last Suffix Your Contact Information Email Phone Home 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 VirginiaWisconsinWyoming ZIP Code Donation Method Preferred Donation Method Payroll Deduction Credit/Debit Card Payroll Deduction Contribution Amount Per Pay Period $5 $10 $20 $25 $50 Other… Please Enter the Amount Per Pay Period $ Number of Pay Periods for Donation One Time 12 pay periods 24 pay periods 26 pay periods 52 pay periods Other… Please Enter the Number of Pay Periods Credit Card Donation Select One One Time Donation Monthly Recurring Donation Amount of your One Time Donation $ Amount donated each month $ 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! Total Annual Contribution TOTAL: $ 0 Donation Details Designation Options Greatest Need Your donation goes to the greatest needs at this time for human services in Rice County. Dolly Parton's Imagination Library Help children be ready for kindergarten. Send a book home each month to one or more children, birth to age 5. Nonprofit Partner Agency Designate a nonprofit you'd like your donation to serve. Nonprofit Partner Agency Please provide nonprofit name. If your designation is not a Rice County United Way nonprofit partner, please provide address and EIN number. See our Partner Agencies. Other United Way Name of alternate United Way with location. Mark all that apply I wish to remain anonymous I'm interested in being a board member I am interested in knowing about volunteer opportunities. Person who is giving with me (spouse, partner, etc.) (if applicable) Agreement My signature below, confirms my pledge as stated above. Signature Sign above We do not sell or share your personal information.
