Lake Region Healthcare Corporation WORKPLACE PLEDGE FORM Preferred Donation Method Payroll Deduction Check Cash Credit Card / Debit Payroll Deduction - Starts in January 2025 Contribution Amount Per Month $5 $10 $20 $25 $50 Other… $ Number of Pay Periods for Donation One Time 26 pay periods TOTAL: $0 Update Check Donation Amount of Check $ Check Number # Cash Donation Amount of Cash $ Credit / Debit Card Donors: Thank you for your support of United Way of Otter Tail & Wadena Counties. To complete your donation by credit or debit card - please click here. Your Name Title First Middle Last Suffix Your Contact Information Employer Email Phone Home Address City State - Select -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 Code Designation Please select your designation: Please select your designation: - Select -United Way of Otter Tail & Wadena Counties (Fergus Falls)Other... Enter other… Agreement My signature below, confirms my payroll deduction request as stated above. Signature Reset Submit Leave this field blank
All Rights Reserved.