English

GIFT FORM
K
Q
FOR OFFICE USE ONLY
GOVERNMENT OF CANADA WORKPLACE CHARITABLE CAMPAIGN (GCWCC) | GCWCC-CCMTGC.ORG | Questions? Call your local United Way.
This campaign is managed by United Way/Centraide.
MR.
MRS.
NAME
MS.
DR. RANK
FIRST
OTHER
MIDDLE
TEL. (
LAST
HOME ADDRESS
CITY
PROV.
English
LANGUAGE PREFERENCE
AGE
)
Y
M
-18
18-24
25-40
GIFT DISTRIBUTION — Choose 1,2,3 or 4 (or combination of each)
D
Please provide your
email/phone number
so we can reach you
in case of any issues
in processing your
donation.
REQUIRED FOR CREDIT CARD DONATIONS
EMAIL
POSTAL CODE
French
DATE
Leaving the workplace? Contact a GCWCC
representative at 1-877-379-6070 to find
Questions about fundraising costs? out how you can continue your support of
Contact your local United Way.
the campaign.
41-55
+55
1 MY LOCAL UNITED WAY
Supporting local lives by supporting community programs. Details: www.UnitedWayGSC.ca. THANK YOU!
0105 8
2 OTHER
1
TOTAL
2
TOTAL
3
TOTAL
4
TOTAL
UNITED WAY of __________________________________________
See GCWCC calendar for list of codes.
01
3
See GCWCC calendar for list of codes.
I WANT TO SAVE LIVES AND HELP FIGHT DISEASE. Divide among all 16 organizations
AND/OR to one or more of the following:
Cystic Fibrosis Canada
Heart and Stroke Foundation
Huntington Society of Canada
The Kidney Foundation of Canada
The Lung Association
Multiple Sclerosis Society of Canada
Muscular Dystrophy Canada
Parkinson Society Canada
Alzheimer Society Canada
ALS Canada
The Arthritis Society
Canadian Cancer Society
Canadian Diabetes Association
Canadian Hemophilia Society
Canadian Liver Foundation
Crohn's and Colitis Canada
01555
4
(minimum $26 per gift per charity)
Visit cra.gc.ca for a listing of charities.
ORGANIZATION or program if applicable
BN/REGISTRATION #
Box 4 has the same code as your local United Way because it processes
and distributes these gifts to the other registered charities.
01058
4
TOTAL
DO NOT publish my name in the Leadership Honour Roll but DO send me information on events.
DO NOT publish my name in the Leadership Honour Roll and DO NOT send me information on events.
FOR LEADERSHIP GIFTS ONLY
THIS IS HOW I WANT TO MAKE MY DONATION
PAYROLL DEDUCTION*
CASH
POST-DATED CHEQUE(s) Make cheques payable to your local United Way.
CHEQUE
Visa
CREDIT CARD
MC
Amex
Include your telephone number in the address section at the top of this form.
Card #
MONTHLY credit card gift of $
for 12 months beginning Jan. 15 for a total of
EXPIRY DATE MM/YY
Signature
Other Giving Options: For information on gifts of life insurance, stock or
bequests, please contact your local United Way.
ONE-TIME credit card gift in the amount of
ATTENTION: Campaign Volunteers
Once detached forward immediately to payroll office.
*FILL OUT THIS SECTION IF GIVING THROUGH PAYROLL DEDUCTION
Q
NAME
PAYROLL OFFICE
DEPARTMENT CODE
PAY LIST
INDICATE HERE HOW YOU DISTRIBUTED YOUR PAYROLL GIFT ABOVE.
2
058
3
4
PRI/REG
I authorize the deduction of
for a total gift of
058
NOTE: Box 4 has the same code as your local United Way because it processes
and distributes these gifts to the other registered charities.
*This information is used to authorize payroll deductions and direct your contributions. This information will be stored in personal information bank PSE 904.
The GCWCC is committed to donor privacy. Personal information is not shared without written authorization or unless required by law. Visit www.gcwcc-ccmtgc.org.
X 26 pay periods,