Events & Programming Career Services Volunteer Give to Adrian Transcript Requests Employment Opportunities College Calendar
 

 

Electronic Funds Transfer Authorization
[Go back to Giving home]

Part 1

Name: ________________________________________________________________

Address: ______________________________________________________________

City: ______________________________ State: _____________Zip:_____________

Phone: (H) __________________________ (W) _______________________________

Email:_________________________________________________________________
By providing an e-mail address I authorize Adrian to send me periodic updates and information.

Part 2

Please deduct $_____each month for ______years.

-Or-

Please deduct $______per month until written notice is received.

Financial Institution: ______________________________________________________

Account Number: ________________________________________________________

Routing/Transit Number: __________________________________________________

Account Type: Savings Checking

I/we wish to designate the gift to:

AC Fund Ridge Student Center

Other ______________ Scholarship ______________

Part 3

I/we hereby authorize the amount below to be dedicated from the account indicated. Your authorization to automatically charge your account has the same effect as a personally signed check to Adrian College. It will allow your financial institution to deduct your pledge amount each month.

Upon receiving your authorization form, we will send a confirmation and notification of when your automatic deduction will commence. A record of your payment will be included in your bank statement, and at year-end, Adrian College will provide you with a detailed report of your monthly gift for tax purposes. All information you provide to Adrian College will be kept in strict confidence. You may terminate your participation in the electronic fund transfer program at any time. However, we ask that you provide a written notification to Adrian College.

Signature: _______________________________________Date:_______________

Mail this form along with a voided check or savings account deposit form to:

Adrian College
Office of Development
110 South Madison Street
Adrian, MI 49221-2575