2011-12 Pledge Confirmation Form
United Way Women's Initiative
* = Required fields
Leadership Giving Levels
Levels:
Alexis de Tocqueville
$10,000 or more
Leadership Circle
$5,000 - $9,999
Chairman's Club Gold
$2,500 - $4,999
Gift Amount $:
If paying by credit card, please complete this form and contact
Jocelyn Bacon
at 713.685.2749.
This gift is payable by:
Payroll Deduction
Cash or Check
Credit Card
Bill Direct
Securities
*Important: In order for your company to receive credit for your gift, please be sure to complete your company's employee pledge card.
2011-12 pledges can be paid any time prior to December 31, 2012
Recognition Preferences
Unless designated below, all names will be published in the Alexis de Tocqueville Society Roster and/or the Leadership Giving Roster with the Women's Initiative designation.
Roster
To give leadership to my peers, I will allow my name to be published in the leadership giving roster. (Please list your name below exactly as you wish to appear in the roster of members.)
Name:
Company:
Anonymous
I wish to remain anonymous.
Young Leaders
I wish to be recognized as a Young Leader (donors age 45 and under who contribute $1,000 or more annually to United Way.)
Diamond Donor
Diamond Donors (donors who have contributed to the United Way for 25 years or more at any level)
First:
Middle:
Last:
Your Spouse's Name:
Your Business:
Your Title:
Business Email:
Company Address:
Company City:
Company State:
Company Zip:
Business Phone:
Business Fax:
Home Address:
City:
State:
Home Phone:
Home Fax:
* Email:
*
Type Numeric Code Below:
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