LEADERSHIP PLEDGE FORM

The Alexis de Tocqueville Society

__ Ordre de Prosperite ($750,000 - $999,999)
__ Ordre de Connaissance ($500,000 - $749,999)
__ Ordre d’Independance ($250,000 - $499,999)
__ La Societe Nationale ($100,000 - $249,999)
__ Ordre de Fraternite ($75,000 - $99,999)
__ Ordre d'Egalite ($50,000 - $74,999)
__ Ordre de Liberte ($25,000 - $49,999)
__ Membres de la Societe ($10,000 - $24,999)

The Leaders’ Circle

__ Blue Ridge Gold ($5,000 - $9,999)
__ Silver ($3,000 - $4,999)
__ Bronze ($2,000 - $2,999)
__ Copper ($1,500 - $1,999)
__ Sustaining ($1,000 - $1,499)

 

(You may print this page to submit your pledge.)

I/We wish to have our name and company listed in recognition materials as indicated below.

First Name__________________________MI_____ Last Name______________________________
Spouse/Partner’s First Name____________________MI___ Last Name__________________________
Home Address________________________________________________________________________
City, State, Zip_______________________________________________________________________
Home Phone Number____________________Work Phone Number ______________________________
E-Mail__________________________________________
Company Name ___________________________ Resort Name ________________________________

Total Gift $_______________ (Paid in full by December 31, 200__)

___I/We wish to remain anonymous.

Payment Information

My Total Gift $______________________

Please check one option below:

___My payment is enclosed.

___Bill me as specified: ___Monthly ___Quarterly___ One Time:(M)____(Y)____

___Charge my debit or credit card:___Visa___M/C___AMEX
Name as shown on card:_____________________________________
Card Number___________________________________Exp. Date________________
Charge my card as specified: ___Monthly ___Quarterly___ One Time:(M)____(Y)____

Signature:_______________________________________________________________

___I wish to donate stock/securities.
Please mail a reminder to me in a (M)____ /(Y) ____

_______________________________________________________
Name of security, # shares, and approximate transfer date

(You or your broker must complete this section or call 828-265-2111 to provide the name
of the stock and the number of shares you will be redeeming. Otherwise, United Way cannot
ensure that you will be properly credited for the stock gift. Thank you.)

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High Country United Way
Serving Avery and Watauga Counties in NC

 (You may print this page to submit your pledge.)