Automatic Donation Authorization

 
Name:
Street address:
City:
State:
Zip code:       Phone:       SSN:
 
I authorize the Institute of Islamic Information and Education (III&E) and its agents to withdraw from my checking account and make adjustments, if and when error occurs. I am voluntarily providing the information of my bank account by submitting a voided check.
 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: 
    III&E, 4390 N. Elston Ave., Chicago, IL  60641-2146

For Office Use Only

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