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Automatic Donation Authorization

 

Muslim Community Center of Greater Pittsburgh

Automatic Donation Authorization

 
Name:
Street address:
City:
State:
Zip code:       Phone:      
 
I authorize Muslim Community Center of Greater Pittsburgh (MCCGP) to withdraw from my checking account and make adjustments, if and when errors occur. I understand that this permission for withdrawl and related information of my bank account (attached voided check) is voluntary on my part.

This authorization will remain in effect until I cancel it in writing.
 
Donation amount: $
Donation interval:
Start date:
 
Signature:_________________________________________ Date:_______________
 
Print out this page, sign and date, enclose a voided blank check, and mail to: 
    MCCGP, 233 Seaman Ln, Monroeville PA 15146

For Office Use Only

 
Bank name:_______________________________________________________________
 
Bank Address:_____________________________________________________________
 
City:__________________________ State:___ Zip:_________ Phone:_______________
 
Routing and Transit Number:_________________________________________________
 
Account Number:__________________________________________________________
 
Date :____________________________________________________
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