Employee Pledge Form 2025

Contact Information

Name

Email

Phone

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

Company Name

Company Name

- Select -Aisin ChemicalAisin DrivetrainAisin USAAisin WorldBeatty InsuranceBlue & Co.Brownstown Central Community School CorporationCity of SeymourCounty of JacksonCrothersville Community SchoolsJCBankLannettNippon SteelParticle DynamicsRose Acre FarmsSeymour Community School CorporationValeoOther Company

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Contact Preference

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	Postal Mail
	Email / E-Newsletter
	Phone

Leadership Giving

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	$10,000 Tocqueville
	$5,000 Jackson Society
	$3,000 Pacesetter
	$1,750 Merit
	$1,000 Booster

Payroll Deduction Amount

Payroll Deduction Amount

- Select -$5$10$15$20Fair ShareOther Amount

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Pay Periods

Pay Periods

- Select -Weekly (52)Bi-Weekly (26)Semi-Monthly (24)Monthly (12)One-Time DeductionOther

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Special Requests / Notes

I would like my gift to remain anonymous.

I would like to learn more about volunteer opportunities at Jackson County United Way.

I give my employer permission to release my employment status to Jackson County United Way if I leave the company so they (JCUW) can contact me about my outstanding pledge.

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