Campaign Award Form Campaign Awards are based on Total Points Earned. Please provide information below. Note: Green-shaded boxes will automatically populate.Official Company Name (for plaques and publication)(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Campaign Coordinator Name(Required) First Last Phone(Required)Email(Required) Campaign GiftsOur Corporate Gift is(Required)Our Employee Campaign Total Gift is(Required)General Campaign TotalSection A: Employee ParticipationPlease note: At least 20% Employee Participation is required to win an award. To Determine Employee Participation: Divide the total number of employees who gave to United Way by the total number of full-time equivalent* employees to get your percentage of participation. *2 part-time = 1 full-time equivalent Example: 100 employees donated to United Way divided by a total of 150 full-time equivalent employees = 67% Contributors to the Heart of Illinois United Way(Required)Please enter a number greater than or equal to 0.Full-time equivalent employees working at our organization(Required)Please enter a number greater than or equal to 0.Percent employee participation(Required)Points earned:5 Points earned for 30-39.9% Employee Participation8 Points earned for 40-59.9% Employee Participation10 Points earned for 60-70.9% Employee Participation12 Points earned for 71-84.9% Employee Participation15 Points earned for 85% + Employee ParticipationTotal points for Section ASection B: Totals Per CapitaTo Determine Per Capita: Divide your Employee Gift Total or your General Campaign Total (listed above) by your total number of full-time equivalent* employees. *2 part-time = 1 full-time equivalent Example: $1,500 employee campaign divided by 30 full-time equivalent employees = $50 per capitaAmount raised through Employee CampaignFull-time equivalent employees working at our organizationEmployee Gift Per Capita— AND —Corporate Gift TotalFull-time equivalent employees working at our organizationCorporate Gift Per CapitaPoints earned:40 Points earned for $20.00 to $44.99 Employee Gift Per Capita50 Points earned for $45.00 to $74.99 Employee Gift Per Capita60 Points earned for $75.00 to $99.99 Employee Gift Per Capita70 Points earned for $100.00 to $124.99 Employee Gift Per Capita80 Points earned for $125 or more Employee Gift Per Capita2 Points earned for Less than $30 Corporate Gift Per Capita4 Points earned for $30.00 to $60.00 Corporate Gift Per Capita6 Points earned for $60.01 to $84.99 Corporate Gift Per Capita8 Points earned for $85.00 to $99.99 Corporate Gift Per Capita10 Points earned for $100 or more Corporate Gift Per CapitaTotal points for Section BSection C: Actions!2 points for each of the following If your organization provided a campaign ambassador, the United Way will add 5 points to your total (not shown on this form). If your organization sponsored a United Way event, the United Way will add 2 points to your total (not shown on this form).Please select actions all that apply(Required) Conducted a Pacesetter campaign Attended campaign coordinator training Payroll deduction was offered and encouraged Set internal campaign goals One-on-one peer solicitation used Endorsements of CEO/Senior Management Endorsements communicated to new hires Conducted a formal retirees giving program Participated in United Way agency tours Campaign info in your company newsletter Developed a company theme for campaign Held an agency fair Held a special event (car wash, book sale, cook out, etc.) Used United Way posters, brochures, flyers Used United Way video during campaign Used company video/personalized UW video Used speaker during campaign Provided thank you to donors Volunteers on United Way Committees Increased employee participation from prior year Increased dollars raised by employee campaign Increased corporate contribution Used the electronic workbook for campaign report Company completed volunteer activity/project Encouraged employees to attend Poverty Simulation Points earned:Total points for Section CTOTALTotal Points from Sections A, B and CGOLD - 90 or more pointsSILVER - 75-89 pointsBRONZE - 60-74 pointsAre you are a new award winner or is your current plaque is full?(Required) We are a NEW award winner Our current plaque is FULL We are a PREVIOUS award winner AND our current plaque is NOT FULL NameThis field is for validation purposes and should be left unchanged.