QC Dividend Enrollment

QC Dividend Enrollment
If you have any questions when filling out the form please contact Nate Berg at nberg@unitedwayqc.org or call 563.344.0321.
Company Information
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Logo

Please upload a high res color version of your company's most recent logo. Accepted file types: PDF, JPG, PNG, EPS.
Cancelof

Social Media Profiles

	URL
Facebook
Instagram
LinkedIn
Twitter
Other

Contact Information
We request that you provide us with contact information for at least two individuals in your organization.
- Executive Contact is the person who should be contacted for information about QC Dividend participation and the company's giving practices.
- Communications Contact is the name of the staff member who oversees the external and internal communications efforts.
As the person completing the form, the confirmation email will be sent to you.
Your Name*

First NameLast Name
Title*
Email*
example@example.com
Phone*
Please enter a valid phone number.
Type of Contact*

Executive & Primary ContactCommunications Contact
Executive Contact*

First NameLast Name
Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Recognition Qualification
Please Select a Giving Percentage*

1%3%5%
For a worksheet to help determine your percentage, click here.

(Important: Worksheet is provided for your use only. Please do not return it to us.)
Organization Profile
Organization Type*

BusinessEducational InstitutionGovernmentOther
Number of Employees*

< 2525-100101-500> 500
Company Ownership*

PublicPrivateNon Applicable
Industry Segment*

Business/ProfessionalEducationFinance/InsuranceHospitality/EntertainmentManufacturing/DistributionPublishing/MediaReal Estate/ConstructionRetail/PersonalUtilities/TransportationOther
Headquarter Location*

Iowa QCIllinois QCOutside of QC
Note: There is no cost to participate in the QC Dividend Program.

If you’d like to make a voluntary contribution to the QC Dividend Program, please use the donate link on the form completion page once you click “submit.”
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QC Dividend Enrollment

Company Information

Contact Information

Recognition Qualification

Organization Profile