| 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.
Name:_________________________________(print)
Address:_______________________________
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 |