UNITED WAY OF MERIDEN AND WALLINGFORD ONLINE PLEDGE FORM
Please fill out the following form completely
Email *
PREFIX
FIRST NAME *
MIDDLE INITIAL *
LAST NAME
STREET ADDRESS *
FLOOR, UNIT OR APT. # *
CITY *
ZIP CODE *
PHONE NUMBER *
COMPANY / ORGANIZATION NAME
PAYMENT METHOD
PLEASE SELECT THE PAYMENT METHOD YOU WOULD LIKE TO USE AND COMPLETE ITS SECTION LISTED BELOW IN THIS FORM
PAYMENT METHOD OPTIONS *
Required
PAYROLL DEDUCTION
PLEASE LIST THE AMOUNT PER PERIOD, # OF PAY PERIODS AND YEARLY PAYROLL GIFT AMOUNT.
Amount per period
Number of pay periods
Yearly payroll gift amount
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
Check amount
CASH
PLEASE LIST CASH AMOUNT.
Cash amount
CREDIT CARD (We accept VISA and MASTERCARD)
PLEASE LIST CARD #, EXPIRATION DATE, BILLING ZIP CODE AND 3 DIGIT CVV #.
Card number
Expiration date (m/y)
Billing zip code
3 Digit CVV number (3 digit # in the back of the card)
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:
Clear selection
Select all that apply
Clear selection
I am a loyal contributor of United Way and have given regularly:
Clear selection
I wish all details of my gift to remain anonymous
Clear selection
ELECTRONIC SIGNATURE (PLEASE TYPE YOUR NAME) *
DATE *
MM
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DD
/
YYYY
THANK YOU FOR YOUR GIFT!
A copy of your responses will be emailed to the address you provided.
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