United Way Pledge Form

Is this an Individual or Corporate Pledge (please select one): *

Individual Pledge

Corporate Pledge

Name of Corporation (if a corporate pledge)

Title *

Mr.

Mrs.

Ms.

Dr.

First Name *

Middle Initial *

Last Name *

Email Address *

Spouse's Name

Spouse's Email

Mailing Address *

City *

State *

Zip Code *

Phone Number *

Phone Number (specify cell, work, or home) (Ex. Cell Number) *

Workplace *

Pledge Amount ($100 min. annually) $ *

Please send me a bill for this pledge *

Once a year (enter date below)

Monthly

Quarterly

United Way of Northwest Georgia will send a bill as a reminder of your pledge.

If you selected once-a-year billing, what month do you wish to be billed?

My gift qualifies me for membership in the following Leadership Giving societies (check all that apply)

Alexis de Tocqueville ($10,000 plus)

Leadership Circle ($1,000-$9,999)

Women's Leadership Council ($1,000 plus)

Young Leaders Society ($365 plus)

Peacock Legacy Society

Please contact me about how to include United Way in my estate plans.

Anonymous

I would like for my gift to remain anonymous.

This gift is in memory or in honor of:

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