CREDIT CARD DONATION FORM

I do hereby authorize AMAZING GRACE MISSION, INC. to charge the following donation to my credit card. This is a one-time gift. Thank you.

Name: ______________________________________________

Address: ____________________________________________

City/State/Zip: ______________________________________

Phone: (________)____________________________________

E-mail: ______________________________________________

Signature: ____________________________________________ (required)

I learned about AGM - Where?____________________________.

Amount of Gift $ _______________________

Visa / MasterCard (circle one).

Credit card number _______________________________________

Expiration date is _____ /_____

Please print and fax this form to: (423) 332-9302 or send to: 

PO BOX 289, Dayton, TN, 37321  (800) 524-4018