UNITED IS THE WAY. Your support fuels hope in the community. WORKPLACE CAMPAIGN PLEDGE FORM Δ I am participating in a workplace campaign at(Required)Please confirm your employer in the drop down menu below. – Select –Americhem – MPAAmeriChem (Swedesboro)Bristol Township School DistrictBucks County Community CollegeBucks County Opportunity CouncilCentennial School DistrictCouncil Rock School DistrictInsacoNeshaminy School DistrictPalisades School DistrictPenn Community Bank (Bucks County)Penn Community Bank (Lehigh Valley)Penn Community Bank (Philadelphia)Pennsbury School DistrictQNB Bank (Bucks County)QNB Bank (Lehigh Valley)QNB Bank (Montgomery County)United Way of Bucks CountyOtherIf other, please describe(Required)CONTACT INFORMATIONYour personal information is confidential and is never sold or shared.Name(Required) Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Newsletter I would like to receive email updates from United Way of Bucks County Preferred Email:(Required) Preferred Phone(Required)I would like to be recognized with my spouse/partner Yes, please include my spouse/partner Spouse/Partner Name First Last Spouse/Partner EmployerComments:What inspired your gift today?(Required)– Select –I LOVE United Way!I want to help ALICE.I heard a powerful story during a campaign event.My coworker inspired me to give.Our team is trying to reach 100% participation.I received help from United Way in the past.Giving is part of our workplace culture.I want to make a difference in Bucks County.I was inspired by our leadership team.OtherIf other, please describe(Required)Pledge InformationPlease select your gift type from the menu below. I would like to support United Way of Bucks County’s mission with my gift. I would like to support United Way of Bucks County’s mission with my gift. Please select a gift type(Required)Payroll DeductionOne-Time GiftI would like to pay by:(Required)Please select your gift type from the menu below. – Select –Credit CardCheck (return check to you company coordinator; make payable to United Way of Bucks County)Cash (return cash to your company coordinator)One-Time Gift(Required) $2,500.00 $1,500.00 $1,000.00 $500.00 $250.00 $100.00 Other Other Amount(Required) Payroll Deduction – Contribution Amount(Required)$5.00$10.00$25.00$50.00$100.00OtherTotal Pledge = Amount x No. of Pay Periods A donation of $19.25 or more per week qualifies you for the Leadership Circle. Other Amount(Required)Pay Periods(Required)I would like to contribute this amount:Weekly = 52 weeksEvery other week = 26 weeksTwice per month = 24 weeksMonthly = 12 weeksMy total contribution amount is: Price: $0.00 My total contribution amount is: Price: $0.00 OPTIONAL FORM FOR TARGETED GIFTSSPECIFIC CAREAs a courtesy to our donors, gifts can be directed to 501(c)(3) health and human service organizations. The minimum annual gift is $50. A processing fee of 12% for lump sum and up to 20% for payroll deduction gifts will be applied (to learn more about how and why fees are assessed, please visit www.uwbucks.org/FAQs). Designations less than $50, and/or with incomplete information, and/or not directed to a qualified organization will be directed to the Community Impact Fund.Agency Information(Required)Agency NameAgency AddressAgency WebsiteTo learn more about how and why fees are assessed please visit, www.uwbucks.org/FAQS.Thank you!If you have chosen to make your pledge using cash or a check, please remit payment to your campaign coordinator. To donate online using a credit card, use the field below and enter your payment information. To finish your pledge, please click submit below. Signature confirmation(Required) I UNDERSTAND THAT CHECKING THIS BOX CONSTITUTES A LEGAL SIGNATURE CONFIRMING THAT I AM SUBMITTING A PLEDGE OR PAYMENT FOR THE UNITED WAY OF BUCKS COUNTY THROUGH MY EMPLOYEE GIVING CAMPAIGN. Total Credit Card(Required)Card Details Cardholder Name All Transations are 100% SSL secure and encrypted. We never store your credit card information. Payments are processed through Stripe. This transaction will appear on your credit card statement as WWW.UWBUCKS.ORG or a variation of STRIPE.PhoneThis field is for validation purposes and should be left unchanged.
