Premier Bone & Joint Premier Bone and Joint PRD Premier Bone and Joint Payroll Deduction Authorization Form Please fill out this form to donate to United Way of Albany County using payroll deduction. There is a designation section on this form if you would like to designate your donation to a specific Community Partner Nonprofit(s). Name * Name First First Last Last Email * Phone * Address (optional) Address (optional) Address (optional) Address (optional) City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Donation Amount I wish to contribute to United Way of Albany County and hereby authorize my employer to deduct a TOTAL ANNUAL contribution of $___ from my pay. * I would like to donate to UWAC through ______ method. * First 2 paychecks of the month (24 pay periods))Proof of one-time donationOther I would like to donate to UWAC through ______ method. You can upload proof of your one-time donation here or ... Drop a file here or click to upload Choose File Maximum file size: 516MB I would like to donate $_____ per paycheck (at the frequency indicated above).. * Please choose which Premier Bone & Joint Giving Campaign you would like to participate in: Elite Giving or VIP Giving Elite Giving Campaign: Contribute through payroll deductions AND for each dollar I contribute, Premier Bone & Joint Centers will MATCH my contribution 2 to1 (i.e. I donate $20, Premier donates $40 VIP Giving Campaign: Contribute through payroll deductions AND for every $25 I contribute annually, Premier Bone & Joint Centers will give me one (1) hour of additional paid time off during the giving year. Designations What would you like your donation to go towards? * Community Funding - Includes all UWAC Community Partner Nonprofits and Programs Specify Designation(s) - Choose specific Community Partner Nonprofits If you would like to designate your donation to a specific United Way Community Partner Nonprofit(s) and/or program, please indicate them here. Community Funding AC Red Cross Ark Regional Services Big Brothers Big Sisters Cathedral Home Community Programs Developmental Preschool and Day Care Downtown Clinic Eppson Center Family Promise of Albany County Head Start Hospice of Laramie Interfaith Laramie Reproductive Health My Front Door SAFE Project Soup Kitchen Wyoming 211 VITA Tax Prep Emergency Funds Additional Contact Info Would you like your donation to remain anonymous? Yes No Would you like to receive a United Way THANK YOU by mail? If yes, please be sure to include your address in the contact section. Yes No Would you like to receive emails with news and updates from United Way of Albany County? Yes No Payroll deduction Authorization By entering your name below you are authorizing United Way of Albany County to contact your place of employment and start payroll deductions on the date previously indicated. * Please include any additional information here: CAPTCHA If you are human, leave this field blank. Submit Start Over last edited by Susie Klein July 11, 2023 3:31 PM Comments Closed
