Company Name

Employee Campaign Coordinator Name

Company Address

Address

Address 2

City/Town

State/Province

- None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

ZIP/Postal Code

Preparer's Information

Preparer's Name

Preparer's Number

Preparer's Signature

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Payment Information

Date you will begin withholdings for the Payroll Deductions:

How will your company remit Payroll Deduction Pledges?

Biweekly

Monthly

Quarterly

Other…

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Payroll Department Contact Name

Phone Number

 

 

Campaign Totals

Total Contribution of Payroll Deductions $

Total Number of Payroll Deduction Donors

Cash/Check Contributions $

Number of Donors for Cash/Check Contributions

Total Credit Card Contributions $

Total Number of Credit Card Donors

Special Event/ Fundraising Total $

Special Event Fundraising Number of Donors

Envelope Total $

Envelope Total Number of Donors

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