First Name Last Name Employer Address City State Zip E-mail Address: * I authorize my employer to deduct the amount entered from my paychek each pay period. Distribute equally amoung NC Community Shares member organizations * Yes No Distribute to NC Community Shares General Operations * Yes No Distribute to specific NC Community Shares organizations as indicated below * Yes No Organization #1 Amount of gift to Organization #1 Organization #2 Amount of gift to Organization #2 Organization #3 Amount of gift to Organization #3 To contribute to a non-NC Shares member, enter name of organization Amount of gift Please give my name to groups I've donated to: Yes No * Required