30 Laurel Street, Hartford, CT 06106
UNITED WAY CAMPAIGN
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CONNECT WITH US:
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LAST NAME
HOME PHONE
HOME ADDRESS (For credit card charges and bill me options, your billing address is required.)
CITY
STATE
COMPANY NAME
EMPLOYEE ID NUMBER
DAYTIME PHONE
PERSONAL E-MAIL ADDRESS
MOBILE PHONE
PREFERRED FORM OF CONTACT
MR/MRS/MS/DR
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FIRST NAME
MI
ZIP
THANK YOU FOR INVESTING IN OUR COMMUNITY THROUGH UNITED WAY. TO SELECT ONE OR MORE INTEREST AREAS, CHECK BELOW. See reverse for an explanations of the interest areas.
AMOUNT $
EDUCATION Children succeed academically and in life.
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FINANCIAL SECURITY Families become financially secure. HEALTH Individuals are healthier.
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BASIC NEEDS Everyone has food, shelter and other essential services.
AMOUNT $
UNITED WAY COMMUNITY INVESTMENT To support all of the above interest areas, check here.
AMOUNT $
By investing in our community through United Way, you improve lives and create measurable, lasting change for all of us. I want my contribution to benefit all United Way partner agencies with the expectation of:
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— Improving the lives of people affected by disability or chronic disease.
AMOUNT $
NEIGHBORHOOD ARTS AND HERITAGE — Diversity through arts and culture programs in Greater Hartford. DIRECT YOUR CONTRIBUTION TO AN AGENCY OF YOUR CHOICE:
AMOUNT $ Agency Name
Agency address and phone number. Please see reverse for more details.* PLEASE CHECK HERE IF YOU WANT TO BE ACKNOWLEDGED BY THE AGENCY YOU HAVE DESIGNATED.
UNITED WAY LEADERSHIP GIVING
UNITED WAY MEMBERSHIP OPPORTUNITIES
I have been a loyal contributor to the United Way Campaign since
I would like to JOIN/RENEW the following membership:
. (yyyy)
My leadership gift or combined household gift of $1,000 or more qualifies me for membership in the Constitution Society.
United Way Women’s Leadership Council. For an additional gift of:
Spouse/Partner gift amount:
Contributions support the Council’s work for families in our community.
$250
Spouse/Partner name:
to United Way, through workplace or individual giving, qualifies membership.
Please list my/our name(s) as follows: I/We prefer our leadership gift to remain anonymous.
PLEASE SELECT YOUR METHOD OF INVESTING
PAYROLL DEDUCTION
I WILL CONTRIBUTE $
$1,000
United Way Emerging Leaders Society. A contribution of $50 or more directed
Employer:
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$500
CHECK PER PAY PERIOD
THANK YOU FOR LIVING UNITED!
TOTAL GIFT $
HOME ADDRESS REQUIRED FOR THESE PAYMENT OPTIONS
CASH
CREDIT CARD
BILL ME
o One time $ ______________ processed upon receipt by United Way
I receive my paycheck:
Enclosed is my check payable to the United Way Campaign.
o Weekly (52/year)
$ TOTAL
o Quarterly $ ______________ per quarter (starting March 2015)
o Every Two Weeks
CHECK #
o VISA
o Semi-Monthly (24/year)
o SECURITIES
o Monthly
Please call United Way to transfer funds at (860) 493-6800. $ (Approx. value)
I authorize my employer to deduct my total annual contribution from my paycheck in equal amounts.
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SIGNATURE (REQUIRED)
FRID ID # _________________ (for Campaign use only)
o Monthly
$ ______________ per month (starting March 2015) o MC
o AMEX
o Discover
CREDIT CARD NUMBER
EXP. DATE
NAME ON CARD
PHONE #
DATE
White Copy - United Way
Yellow Copy - Company
Pink Copy - Employee
x493
0514-55K