Please print this form, complete all fields, sign it and mail it with a voided check to: 

The Christophers, Development Department, 5 Hanover Square, 11th Floor, New York, NY 10004

Contribution

I'd like to use electronic funds transfer to support The Christophers through a monthly contribution of $__________________.

_____ Monthly (12x per year)      _____ Bi-Monthly (6x per year)      _____ Quarterly (4x per year) 

Contact Information

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Name:  ____________________________________________

Email:  _____________________________________________      Phone Number: __________________________________

Account Information

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Agreement for Pre-Authorized Drafts
I (we) hereby authorize The Christophers to initiate debit entries to my (our) bank account indicated below and the financial institution named below, to debit the same to such account.         * All financial information is required.

Financial Institution:  ______________________________________

Branch:  __________________________________________      City, State, Zip:  ______________________________________

Bank Routing Number:  _____________________________________

Account Number:  _________________________________________      Account Type:       ______ Checking          ______ Savings

Start Date:  ____________________________

Authorization

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This authority is to remain in full force and effect until The Christophers has received written notification from me (or either of us) of its termination in such time and in such manner as to afford The Christophers a reasonable opportunity to act on it.

Name(s) ________________________________________

Signature : ________________________________________ DATE : _______________

Signature : ________________________________________ DATE : _______________

In accordance with Internal Revenue Service regulations, we are required to advise you that no goods or services were provided in exchange for your gift.