Yes, I want to contribute regularly to WBVN through the automatic fund transfer plan.  My voided check is enclosed.  Deduct the amount indicated each month on the day shown.  This authorization is the same as if I personally mailed a check.  It remains in effect until I notify WBVN that I wish to discontinue contributions.  WBVN is registered and authorized by the State of Illinois and the Internal Revenue Service as a non-profit organization.  All gifts to WBVN are tax deductible.



City:__________________________________  State:____________    Zip:________

Phone:____________________    Amount to Pledge:____________________

WBVN Identification #, if you know it, (4 digit number found on the front of your Newsletter label):_________

I would like to contribute using: Checking _________ Credit/Debit _________

If using Credit or Debit, please complete the below fields:
Name as it appears on card: _______________________________________________
Type of Card: Visa _________ MasterCard _________ Discover _________
Account Number: ________________________________________________________
Expiration Date: _________________________________________________________

I prefer for the transfer to take place on the ________ (day of month - between 1st and 28th) of each month.

Signature:_______________________________ date:_______________________

Mail this form with a voided check (if using checking) to: WBVN, P.O. Box 1126, Marion, IL.  62959