Faithful Friends Club – Three Rivers Humane Society

Yes I think every life is worth saving!

Please withdraw my monthly contribution from my: *

I would like to donate the following amount monthly to help.

If your donation is $50 or more, what name would you like on the kennel plaque?

Your Information

Please fill out the information below.

Donor 1 Name *

First

Last

Donor 2 Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Financial Institution Information

Automatic Account Withdrawal Authorization

By initialing electronically at the end of this paragraph I (we) hereby authorize Three Rivers Humane Society hereinafter called TRHS to initiate debit entries to my (our) Checking Account or Credit Card account as indicated below at the depository financial institution named below, hereinafter called Depository, and to debit to the same such account. Monthly Withdraws will be initiated on the 5th (or next closest business day) of the month.

Please type your name to indicate your agreement with the above statement. *

Credit Card Information

Credit Card Issuer:

Credit Card Type (Please note we do not accept American Express)

Visa
Mastercard
Discover

Credit Card

Card Number

Security Code

Name on Card

Expiration/

Checking/Savings Account Information

Depository Name

Is this account a checking or savings account?

Checking
Savings

Depository Routing Number

Account Number

By signing your name as an electronic signature below you agree that this authorization is to remain in force and effect until TRHS has received written notification from me (or either of us) of its termination in such time and in such manner as to afford TRHS and Depository a reasonable opportunity to act on it.

Signature (Use a mouse to sign your name)

Captcha *

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