Name: _____________________________ Faith and/or Labor Affiliation ____________________

 

Address: __________________________ City, State, Zip Code:  __________________________

 

Telephone: _________________________ Email: ______________________________________

 

I want to give a donation by □ Check                    □ Credit card                        □ Cash

 

$250_________ $75____________ $50 ______________ $25 _______ Other ___________

 

□ Charge my credit card for the amount indicated above

 

_________________________________________    _____/_____ 

Visa/Master Card Number                                                   Expiration Date

 

A donation of $25 or more will count as your annual membership fee.  Donations are tax deductible.

    

 

   □ I want to join the Sustainer’s Monthly Automatic Giving Program!

 

   □ $10/month        □ $5/month       □ $2/month        □ Other $______/month

 

I authorize the ICWJ to deduct the above amount from my □ checking or □ savings account each month. This authorization will remain in effect until I (we) notify ICWJ orally or in writing to cancel it.

 

   ____________________________________                        ______________________

        Signature                                                                          Date

 

Please make the deduction from my account on the            1st of the month

                        (circle one)                                                               15^th of the month

 

Please attach a voided check to this form