Phi Upsilon Chapter

PHI UPSILON CHAPTER

PHI GAMMA DELTA

UNIVERSITY OF NORTH ALABAMA

AUTHORIZATION AGREEMENT FOR AUTOMATIC PAYMENTS

CREDIT CARD

______

I (we) hereby authorize THE FRATERNITY OF PHI GAMMA DELTA, PHI UPSILON CHAPTER'S GRADUATE ASSOCIATION, herein called COMPANY, to initiate all debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my CREDIT CARD.

BANK THAT ISSUED CREDIT CARD: ______

TYPE OF CREDIT CARD: VISA, MASTER CARD, (Circle one) Cannot do Amex Express

CREDIT CARD NUMBER ______-______-______-______

ISSUE DATE OF CARD: ______

EXPIRATION DATE OF CARD: ______

NAME AS IT APPEARS ON CARD: ______

AMOUNT OF DONATION: $______

THIS DONATION IS MONTHLY OR YEARLY OR ON DEMAND (circle one)

DATE OF DONATION TO START: ______

YOUR HOME MAIL ADDRESS: ______

YOUR PHONE NUMBER:______

YOUR E MAIL ADDRESS:______

NOTE:

ACCOUNT DRAFTS WILL BE DONE ON OR AROUND THE 15TH OF EACH MONTH.

FORMS CAN BE MAILED OR FAXED TO: INFO CAN BE E-MAILED ALSO.

BILL ROGERS

P.O. BOX 1144

Killen, AL 35645

Fax: 256-272-0580 ( auto mode)