Online Pledge Form Personal InformationFirst Name *Last Name *Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEmail *Phone Please combine my gift with my spouse: Spouse's name and employer Payroll DeductionEMPLOYER - Please select your employer from the drop down list UnityPoint Trinity MuscatineMuscatine High SchoolCentral Middle SchoolWest Middle SchoolColorado ElementaryFranklin ElementaryGrant ElementaryJefferson ElementaryMadison ElementaryMcKinley ElementaryMulberry ElementaryMCSD Administrative Building/MaintenanceMuscatine Schools TransportationUnited Way of MuscatineNot ApplicablePayroll Deduction I want to contribute the following amount each pay period:$50$25$10$5Other (fill in below)Other Amount Total Annual Payroll Deduction Direct GiftDirect Gift Bill Me Annually (March)Bill Me QuarterlyMy Total Annual Gift My Gift of $1,000 or More qualifies me for membership in the Pearl City Leadership Society.I prefer that my gift remain anonymousPlease include me in Women United (unitedwaymuscatine.org/womenunited)Please list my/our name(s) as follows: Imagination Library In addition to my annual contribution, I would like to provide a child with one book a month for a year at the cost of $25/year.Number of children you wish to sponsor: Please add my Imagination Library amount to my: Payroll Deduction TotalDirect Gift Total Comments VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
