Name *Employee Number Choose a County (Check All That Apply): RocklandOrangeBergenPassaicSullivanSussexOtherLocal 503 Member: *YesNoPlease choose only one: I will keep my donation the same as last year (you do not need to complete any other part of this form - click submit)I am a new donor or I will be making changes from last year's donationIf Other: Amount of Donation Community Impact Percentage Allocated across United Way programs to make the most positive impact in the areas of education, financial stability and healthDonation Acknowledgement Requested YesNoSpecific Charity Percentage Name of Charity (Optional) Donation Frequency: One-Time Payroll DonationOne-Time Credit Card Donation (After Form Submit, Complete Payment Via Link Provided)Check (Mail To Lisa Culhane At O&R)Weekly Payroll Deduction (Local 503)Bi-Monthly Payroll Deduction (Management)General Comments EmailSubmit
