Automatic Donation (ACH)

Name *

First

Last

Address

City

State

Zip Code

Phone Number

Bank Name

Bank Routing Number

Bank Account Number

Email *

Please check

I hereby authorize the Muslim Society of Memphis to initiate debit entries to my account number listed above. Furthermore, I authorize my bank to debit the same to such account. The monthly deduction amount starting month, and ending month (if applicable) are as follows:

Monthly Deduction Amount

Start Month

End Month (if applicable)

The authority will remain in effect untill the end month mentioned above or untill I notify Muslim Society of Memphis to cancel it in such time as to afford the financial institution a reasonable time to act on it. I may also stop payment of future debits from my account by notifying my bank in such time as to afford the bank a reasonable time to act on it.
I authorize for account to be debited

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