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: Monthly Quarterly (Jan, Apr, July, Oct) Biannually (Jan, July) Annually (December) 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 :____________________________________________________