Name________________________________
E-mail  _________________  Phone _________________
Address ______________________________
City  ___________________________State/Zip_________________
Signature________________________________________________
(  )  Please send me information to include my local United Way in my will, trust or estate plans.

(  )  I would like to help my communtiy as a volunteer.

My daytime phone number is _(    )___________________________

PAYMENT INFORMATION
(  )  Payment Enclosed_____________________
(  )  Bill me once on _______________________
(  )  Bill me Monthly Starting_________________
(  )  Bill me Quarterly Starting________________
TOTAL PLEDGE            $__________________
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