AMAZING GRACE MISSION
AUTOMATIC CREDIT CARD GIFT
AUTHORIZATION FORM
(print & complete & mail)
 

I,____________________________________, do hereby authorize Amazing Grace Mission to charge $_____________________ per month to my Visa / MasterCard (circle one).

My credit card number is___________________________________and the expiration date is _____/ ____.

I acknowledge that these debits are charitable donations, and I will receive no goods or services from Amazing Grace Mission in exchange for them other than intangible religious benefits.

This authorization shall be effective until I notify Amazing Grace Mission in writing to cease this monthly debit to my credit card. Such notice must be sent by letter mailed to P.O. Box 289, Dayton, TN37321or by fax to 423-332-9302.

PERSONAL INFORMATION AS IT APPEARS ON MY CREDIT CARD:

Name: ____________________________________________________

Address: __________________________________________________

City/State/Zip: _____________________________________________

Phone: (________)__________________________________________

Signature: _________________________________________________ (required)

Please let us know where you heard about Amazing Grace Mission? ____________________________________________________________

____________________________________________________________

Please mailed to P.O. Box 289, Dayton, TN37321 or by fax to 423-332-9302.

All credit card charges will be posted on the 10th of the month immediately following receipt of this authorization form.

Monthly charge will cease on the 10th of the month immediately following the receipt of notice canceling this authorization form.

Amazing Grace Mission, PO Box 289, Dayton,TN 37321 or fax  423-332-9302