Name:

Address:

City: State: Zip:

Employment / Business:

Occupation:

Work Phone: Home Phone: Fax:

Email:

Company Prospect:

Number of Employee in Georgia:

Number of Employees Total:

Can employees giving to charities at work through payroll deduction?

q Yes

q No

Which category best describes your workplace giving campaign?

q United Way only

q United Way and other health and human welfare organizations

q Genenal fund that is shared among a variety of charities

q Other

Would you help Earth Share of Georgia approach your business?

q Yes

q No

Can we call you to discuss this in more detail?

q Yes

q No

Is there someone else you recommend we contact at your business?

Name: Phone:

Please list any other companies or contacs you are willing to approach on behalf of Earth Share of Georgia: