Automatic Donation Authorization

Muslim Community Center of Greater Pittsburgh

MCCGP Policies

Muslim Community Center of Greater Pittsburgh (MCCGP)

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 error occurs. 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 :____________________________________________________