Employee Charitable Giving Donation Form
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32004/2005 Employee Charitable Giving Donation Form
1. Personal Information
Employee Name:___________________________________
Nike Employee Number:___________________________
Work Email Address:________________________________
Home Address:__________________________________
Daytime Phone:____________________________________
City/State/Zip:___________________________________
!
!
" Please release my name and home address to the organization(s) I have designated.
"
!
" Please release my name only.
!
"
!
" Don’t release my name or my address.
!
"
2. Total Annual Contribution Amount: (minimum annual donation is $25.00 per organization)
I authorize my Annual Payroll Deduction gift as $________________ for my 2005 charitable contribution as follows:
(Please choose one)
!
" Please deduct from my first paycheck in January 2005 OR
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"
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" Please deduct evenly twice a month from my paychecks in 2005
!
"
3. Designated Organizations: I want to donate to the following organization(s):
Please write in any U.S. tax-exempt 501(c)(3) non-profit charity. Be sure to provide all of the information requested below. Please print
very clearly.
Non-Profit Organization(s)
Organization Name:
Donation supports youth physical fitness, sports or recreation
YES
NO
Address:
Total Annual Amount I am Donating ($25.00 minimum):
City/State/Zip:
$
EIN #:
Total Annual Amount Matched by Nike ($25.00 minimum):
Phone Number: (
)
$
Organization Name:
Donation supports youth physical fitness, sports or recreation
YES
NO
Address:
Total Annual Amount I am Donating ($25.00 minimum):
City/State/Zip:
$
EIN #:
Total Annual Amount Matched by Nike ($25.00 minimum):
Phone Number: (
)
$
Organization Name:
Donation supports youth physical fitness, sports or recreation
YES
NO
Address:
Total Annual Amount I am Donating ($25.00 minimum):
City/State/Zip:
$
EIN #:
Total Annual Amount Matched by Nike ($25.00 minimum):
Phone Number: (
)
$
Total Annual Contribution (Not including Nike
$
Match):
(Must equal total shown in #2 above)
4. Authorization: I hereby authorize Nike to deduct the amount shown above from my Paycheck(s).
______________________________________________
_____________________
Signature
Date
5. Submission: Please return Donation Form by October 29, 2004 via US mail to: Nike Charitable Giving P.O. Box 7215 Princeton,
NJ 08543-7215. Questions? Call 1-888-671-4438 or email . If you prefer to register your gift online, the website
will be live from October 22, 2004 through October 29, 2004 and the link will be provided in an email on October 22, 2004.
Forms received after October 29, 2004 will not be processed.
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