2010 Haiti Pledge Form - FINAL

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2010 Haiti Pledge Form - FINAL Powered By Docstoc
					                                                                                      HOUSTON INDEPENDENT SCHOOL DISTRICT

                                                                                          HAITI RELIEF CAMPAIGN · PLEDGE FORM
                                                         *PLEDGE FORM MUST BE SIGNED AND RETURNED TO STRATEGIC PARTNERSHIPS (Therese Cole or Michelle Vega)

                                                                                                   PLEASE PRINT ALL INFORMATION

Employee Name:

Department/School Name:                                                                                                           ** Mailing Address for Confirmation Receipt

                                                                                                                                  Street Address:
                                                                                                Dept./School
Employee No.:                                                                                   Pay Location No.:                 City, State, & Zip Code:


To make your charitable contribution, print out this form, and choose one or more federation/charity from the 2010 Haiti Relief Campaign Charity List on the HISD Portal Site. In the
spaces provided below, write in the name and number of the federation/charity, indicate the method of payment, and the amount you wish to contribute. Make copies for additional
contributions as needed.

*THIS FORM IS NOT NEEDED IF DONATING ONLINE THROUGH THE CCC WEBSITE. If using this form, turn in to Strategic Partnerships. (Therese Cole or Michelle Vega)


                                                                                             PLEASE MAKE A COPY FOR YOUR RECORDS

                   H                                                        Name of Charity:
                   Charity Code #:

                   METHOD OF PAYMENT (Please check only one):
                       Payroll Deduction
 SELECTION ONE




                       One Time Contribution                                $
                                                                             Total Deduction Amount on
                                                                            3/3/2010 Paycheck (Minimum
                                                                            $2.00; Whole Dollars ONLY)


                       Check/Money Order
                       Check/Money Order                                    $
                                                                            Total Amount (Minimum $2.00;
                       Make Payable to Charity Name                             Whole Dollars ONLY)




                   H                                                        Name of Charity:
                   Charity Code #:

                   METHOD OF PAYMENT (Please check only one):
 SELECTION TWO




                       Payroll Deduction
                       One Time Contribution                                $
                                                                             Total Deduction Amount on
                                                                            3/3/2010 Paycheck (Minimum
                                                                            $2.00; Whole Dollars ONLY)


                       Check/Money Order
                       Check/Money Order                                    $
                                                                            Total Amount (Minimum $2.00;
                       Make Payable to Charity Name                             Whole Dollars ONLY)



                   H                                                        Name of Charity:
                   Charity Code #:

                   METHOD OF PAYMENT (Please check only one):
 SELECTION THREE




                       Payroll Deduction
                       One Time Contribution                                $
                                                                             Total Deduction Amount on
                                                                            3/3/2010 Paycheck (Minimum
                                                                            $2.00; Whole Dollars ONLY)


                       Check/Money Order
                       Check/Money Order                                    $
                                                                            Total Amount (Minimum $2.00;
                       Make Payable to Charity Name                             Whole Dollars ONLY)


PAYROLL DEDUCTION AUTHORIZATION: I hereby authorize the payroll deduction(s) of the amount(s) shown above to the proper charity as indicated. I understand that this authorization may be revoked
by me in writing at any time before it expires and may not be reinstated.


                                                                                                                                  Signature                                     Date


                   Yes, I would like a confirmation receipt mailed to me from the charity(ies) listed above.**

                                                                          THANK YOU FOR YOUR GENEROUS CONTRIBUTION