Organization Information Company / Organization Name: Contact Person: Address: City: State: - Select -Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Phone: Fax: Email: Number of Employees Full-time Employees: Part-time Employees: Total Contributions / Pledges Employees Paid in Full Employees making a one time donation by cash or check. Number of Employees Amount Payroll Deduction Employees Employees wishing to have donations witheld from each paycheck. Report to your company payroll or human resource office. Number of Employees Amount To Be Billed By United Way Employees who wish to be billed directly by UWNEK. Provide specific billing instructions and addresses. Number of Employees Amount Total Employee Contribution Do not include corporate gift. Number of Employees Amount Corporate / Company Contribution Do not include any employee contributions. Amount Grand Total All company and employee donations. Amount CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit