FIRST STATE BANK Preferred Donation Method Options - Select One Payroll Deduction Check Credit Card Amount Per Pay Period Frequency you are Paid - None -Bi-Weekly (22 times/yr) Amount of Check If donating by credit card, please CLICK HERE to exit this form and complete your online transaction. Employer Employer Name Location/Department Name My Contact Information First Name Last Name Home Address City State - None -Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code Email Address Office Phone Cell Phone County Designation Cooke Wise Denton Grayson Cooke County - Chisholm Trail Club Members Wagon Driver $500-$999 Wagon Master $1,000-$1,999 Scout $2,000 and up Denton County - Pillar Givers Platinum Pillar $1,000-$2,499 Capstone Pillar $2,500-$4,999 Grayson County - Circle of Giving Ben Blackburn Circle of Honor $10,000+ Grayson Circle $5000 to $9999 Gold Circle $2500 to $4999 Silver Circle $1000 to $2499 Bronze Circle $500 to $999 Wise County - Major Donors Bronze $1,000-$2,999 Silver $3,000-$9,999 CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Donor Notes (Specify Designated Agency or "In Honor Of" here) Submit
