For PDF format
(free
reader available), click
here. Otherwise, follow instructions below:
Please print this page, complete the form, sign
it, and mail it to:
Tracey Sperry, Development & Research Manager
Scleroderma Foundation
300 Rosewood Drive, Suite 105
Danvers, MA 01923
|
 |
| Installment
Giving Program Enrollment Form |
| Personal Information: |
| Name: _____________________________________________________________________ |
| Address: ___________________________________________________________________ |
| City: ______________________________ State: __________________
Zip: ____________ |
| Home Phone: _______________________ Work Phone:
____________________________ |
| Email: ________________________________ |
| I will make an ongoing monthly gift of $________
per month. |
| I will make a total gift of $_________ in _______
monthly installments of $_____________ |
| Make my installments via Automatic Credit Card
payments: |
| Mastercard VISA |
| Card number: __________________________ Expiration
Date: _______________ |
| Signature: __________________________________________________________________ |
Make my installments via Electronic Funds Transfer:
(please attach a voided deposit slip) Checking
Savings |
| Bank Name: ________________________________________________________________ |
| Bank Address: ______________________________________________________________ |
| Routing number: ____________________ Account number:
_________________________ |
| Authorization With
my signature, I authorize the Scleroderma Foundation
to initiate debit entries to the indicated account
or credit card each month for the amount stated
above. This authority will remain in effect until
I notify the Scleroderma Foundation of any change
or cancellation in writing, and they have adequate
time to act on my request.
All
installment plan payments will be processed on
the 15th of the month or the following business
day. |
| Signature: _________________________________________
Date: ___________________ |
| My gift is given (check one): in honor of
in memory of |
| Name: ____________________________ Please notify:
____________________________ |
Donors of $25 or more annually can be acknowledged
as members:
I am not interested in member benefits. |
