Loyal Contributor On-line Registration Form

We want to recognize you as a Loyal Contributor. If you have donated to United Way, in any community, for ten or more years, you are a Loyal Contributor.

Please let us know you are a Loyal Contributor by completing the form below.

Full Name

Street Address

City   State    Zip

Home or Cell phone number

Work phone number

Preferred email is work or home

Preferred email

Employer

I have been donating to United Way since year (approximate is okay)

My gifts have been:  Individual or Combined with a member of my household

Name of combined giver

I am interested in a planned gift to United Way:  Yes or No

Enter above code