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UNITED WAY OF MERIDEN AND WALLINGFORD ONLINE PLEDGE FORM
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Email
*
Your email
PREFIX
Your answer
FIRST NAME
*
Your answer
MIDDLE INITIAL
*
Your answer
LAST NAME
Your answer
STREET ADDRESS
*
Your answer
FLOOR, UNIT OR APT. #
*
Your answer
CITY
*
Your answer
ZIP CODE
*
Your answer
PHONE NUMBER
*
Your answer
COMPANY / ORGANIZATION NAME
Your answer
PAYMENT METHOD
PLEASE SELECT THE PAYMENT METHOD YOU WOULD LIKE TO USE AND COMPLETE ITS SECTION LISTED BELOW IN THIS FORM
PAYMENT METHOD OPTIONS
*
Payroll deduction
Personal check
Cash
Credit card
Required
PAYROLL DEDUCTION
PLEASE LIST THE AMOUNT PER PERIOD, # OF PAY PERIODS AND YEARLY PAYROLL GIFT AMOUNT.
Amount per period
Your answer
Number of pay periods
Your answer
Yearly payroll gift amount
Your answer
PERSONAL CHECK
PLEASE LIST CHECK # AND CHECK AMOUNT.
MAIL CHECK PAYABLE TO UNITED WAY OF MERIDEN AND WALLINGFORD.
ADDRESS: 35 PLEASANT ST., SUITE 1E, MERIDEN, CT 06450.
Check number
Your answer
Check amount
Your answer
CASH
PLEASE LIST CASH AMOUNT.
Cash amount
Your answer
CREDIT CARD (We accept VISA and MASTERCARD)
PLEASE LIST CARD #, EXPIRATION DATE, BILLING ZIP CODE AND 3 DIGIT CVV #.
Card number
Your answer
Expiration date (m/y)
Your answer
Billing zip code
Your answer
3 Digit CVV number (3 digit # in the back of the card)
Your answer
WE WOULD LIKE TO KNOW MORE ABOUT YOU AND ABOUT THE WAYS WE CAN CONTINUE SHARING UNITED WAY'S MISSION
Please answer the following questions.
I would like to learn more about United Way's work in:
Education
Financial Stability
Basic Needs
Clear selection
Select all that apply
I have included United Way of Meriden and Wallingford in my estate plans
Please send me information on United Way of Meriden and Wallingford planned giving opportunities
Clear selection
I am a loyal contributor of United Way and have given regularly:
10 years or more
25 years or more
Clear selection
I wish all details of my gift to remain anonymous
Yes
No
Clear selection
ELECTRONIC SIGNATURE (PLEASE TYPE YOUR NAME)
*
Your answer
DATE
*
MM
/
DD
/
YYYY
THANK YOU FOR YOUR GIFT!
A copy of your responses will be emailed to the address you provided.
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