Asbury University Monthly Giving Program Enrollment Form printable pdf download

Asbury University Monthly Giving Program Enrollment Form

Office of Development

development @asbury.edu

Asbury University

859-858-3511 ext. 2136

One Macklem Drive

800-888-1818 ext. 2136

Wilmore, Kentucky 40390

fax: 859-858-3921

MONTHLY GIVING PROGRAM ENROLLMENT FORM

Please enroll me in Asbury University’s automatic monthly giving program. I would like

my charitable contribution of $

to be designated to:

______________________________

Fund for Asbury University: Student Scholarships

Other:

___________________________________________________________

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Please choose from one of the following payment types:

Credit Card Transaction

Card Type:

Visa

MasterCard

Discover

American Express

Name on Card:

Exp. Date:

_____ _____

_____ _____ _____ _____

Card Number:

_____ _____ _____ _____

Savings/Checking Account Withdrawal (please attach a voided check)

Name on Account:

Financial Institution Name:

Financial Institution City, State, & Zip:

Type of Account:

Savings

Checking

Routing Number:

_____ _____ _____ _____ _____ _____ _____ _____ _____

Account Number:

Routing Number

Account Number

_____________________________________________

I authorize Asbury University to automatically charge my credit card or deduct from my Savings/Checking account on the:

day of each month

Beginning Month:

____ ____

____ ____ ____ ____

This authorization will remain in effect until Asbury University receives further written notification from the undersigned.

Signature:

Date:

Asbury University Monthly Giving Program Enrollment Form

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