United Way of Clinton County Name:_____________________________________ Address:____________________________________ Home Phone:_________________ Work Phone:_________________ In recognition of the needs of my community and its people, I will lead by example & contribute    $________________ to United Way of Clinton County. Paid by check #________    or   _________Cash Amount Signature________________________ Date_________________

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United Way of Clinton County Name:   __________________________________ Company:_______________________  Department:______________________ Home Address:  ____________________________ In recognition of the needs of my community and its people, I hereby subscribe the sum of   $________________ to be paid (please check the appropriate boxes.) Pledge My : Signature________________________ Date_________________