IIT Combined Charitable Campaign     United Way site
Print and sign this form, and send it to: Human Resources, Room 302, Main Building.
Name:
Dept:  
 
Signature: _____________________________    Date: ___________
A.
I authorize the following payroll deduction pledge per pay period
United Way  
$  
Ending 12/31 of current year
Continuously until changed
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I wish to make a one-time contribution of the following amount, as a payroll deduction:
United Way  
$  
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
 
I am enclosing a one-time contribution of the following amount:
United Way  
$ Make check payable to United Way.
B. Share gift among all organizations.
  Please direct my gift to the organizations below:
 
United Way Agencies (click for list)
Name Annual Amount
  $
  $
  $
  $