Part 1:
Personal Information

Yes, I'm a NEW Contributor to United Way

First Name

Last Name

Employer

Work Phone Number

Home Phone Number

Your Email

Home mailing
Address 1

Address 2

City

State

Zip

Part 2: My United Way Pledge

Please select one option
Fair Share Partner ( 1 hours pay per month)
Distinguished Partner ( 1.5 hrs pay per month)
Elite Partner (1% of Salary) please specify
other - please specify
Leadership Partner ($500 or more).  To encourage other donors, you have my permission to use my name(s) in the Leadership Brochure.     

Select Frequency of Your Gift. Weekly (52x year) Bi-Weekly (26 x year) Semi-Monthly (24 x year) Monthly (12 x year) One Time Donation Billing Address as above

Part 3: Payment method

Total Pledge $

Please select one of the five choices and fill in any additional information required for that method Bill Me Monthly ($50 Gift Required for this Option) Bill Me quarterly Bill Me Annually Credit Card

Billing Address mailing (fill this out if you choose the Bill Me option)
Billing Address 1
Billing Address 2
City  State  Zip
Additional Information

Credit Card Information

Credit Card Number 
Exp. Date 

Part 4: Options & Descriptions

Please Check Only One Option
1. Community Impact dollars are allocated where they are most needed in Wilkes County. Our Fund Distribution & Community Needs Process include more than 60 volunteers, visiting agencies and researching programs requesting funding to make decisions that best meet the community’s needs.  

2. Impact Areas Your gift will be distributed in Wilkes County to fund Impact Areas listed below.
       please check your choice
       Crisis/Basic Needs:
        Family & Literacy:
        Health & Counseling:
        Persons With Disabilities:
        Senior Services:
        Youth Activities:
        Youth At Risk:

3. SPECIFIC CARE* Your gift will be given to the United Way agency of your choice or to another community United Way.
       Partner Agency:         Amount $
       Partner Agency:         Amount $
          United Way of:         Amount $
* You may designate up to 75% of your gift to a specific agency. The remaining 25% is distributed to Community Impact..

Part 5: Miscellaneous Information

Please select the options you are interested in
I'd like to receive information about volunteer opportunities with
I'd like to provide for future care in Wilkes County and would like to receive information on how to include United Way in my will.
Please check here if you have been helped by a United Way funded program and you'd like to share your success story with others in the community. (You will be contacted by United Way.)

Financial information about this organization and a copy of its license are available from the State Solicitation Licensing Branch at 919-807-2214. This license is not an endorsement by the State.