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2020/2021 One Team, One Mission - Pledge Form
Pledge Form Delta Dental
Invalid Submission Values
Step 1: Donor Information
First Name
(required)
Last Name
(required)
Mailing Address
(required)
City, State, Zip
(required)
Phone Number
(required)
Email
(required)
Example: janedoe@fakeemail.com
Step 2: How Would You Like To Give?
(Please complete one of the options below.)
Option A:
Payroll Deduction - starting January 1
Check this box if you want to be a CHAMP donor by donating an hour of your pay per month. (2021 salary) If you select this box you can skip down to Step 3.
Keep it simple...make me a CHAMP donor!
I want to select a specific annual donation amount. This is the total amount I would like for my 2021 pledge. It will be divided by 24 pay periods.
Example: 1,000.50
Option B:
Credit Card
Credit Card Charge Frequency - begins January 1, 2021 unless another date is selected from the calendar below
Select an option
One-Time Charge for the amount below
Monthly for the amount below
My pledge amount
Example: 1,000.50
Please start my credit card contribution - begins January 1, 2021 unless another date is selected from the calendar below
Example: ##/##/####
Credit Card Number
Expiration Date (MM/YY)
CVV (code on back of card)
Step 3: Pledge Acknowledgment & Confirmation
Are you a CHAMP giver? (You are pledging to donate at least an hour of your pay, each month, to CAUW.)
(required)
Yes
No
Are you a LEADERSHIP Giver? (May be combined with your spouse)
(required)
$500+
$1000+
No (less than $500 pledge)
For LEADERSHIP Giving, please combine my gift with my spouse. (List spouse and their employer.)
I would like my thank you to be sent via
(required)
Select an option
Email
Letter
No thank you necessary
I wish my gift to remain anonymous. (Please note: If you choose this option, you will not show up on any listings, even if you are a CHAMP or LEADERSHIP Giver.)
(required)
Yes
No
Signature
(required)