PLEASE COMPLETE, SIGN, PRINT AND RETURN THE ENTIRE FORM TO LYNNETTE LEMEN AT THE CENTERVILLE CSD ADMINISTRATION OFFICE
E-mail submission of completed form will not be accepted.

APPANOOSE COUNTY UNITED WAY
SCHOOL EMPLOYEE DONATION CARD

NAME:	 PLEASE PRINT

TOTAL DONATION AMOUNT: $ 	

………………………………………………………………………………………………………………………………………………………………… Please indicate how you, as an employee of the Centerville CSD, wish to donate

Check
Cash $ 	
Total dollars enclosed with this form

Payroll Deduction:
I hereby authorize my employer to deduct 	consecutive
(# of pays)
pays of $ 	per pay period with final pay ending on 	for the
(date)

2017-18 school year.

Date	Signature