Longview Leadership Society (LLS) Pledge Form

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Information for the United Way office:

Name*

Address*

City, State and Zip Code*

Telephone

Birth Date

E-mail Address

Would you like to receive the LLS award?

Yes
No

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Listing Information:

I agree to have my name published along with other Longview Leadership Society members to encourage others to contribute.

Please list my (our) name(s) as follows:

2. Listing Information:

I prefer to remain anonymous.

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TOTAL PLEDGE*

Payment Options:

Check (Mail to GLUW)
Payroll deduction through my employer
Electronic Transfer - monthly or quarterly. You will be contacted with further details.
Billed MONTHLY to my home address
Billed QUARTERLY to my home address
Billed Once on

Or once on

My field

Credit Card