91³Ô¹ÏÍø

Thank you for inquiring about our Electronic Funds Transfer charitable contribution program. By completing and returning this form, you will set up an automatic and consistent method for making your annual contribution to 91³Ô¹ÏÍø. Your account will be charged around the 10th of each month. Your bank statement will reflect a debit from 91³Ô¹ÏÍø. Please fill out the information below and attach a voided check to this authorization form. You can anticipate that the first transaction will take up to 30 days after we receive this authorization.

You may cancel this authorization at any time by sending your request in writing to 91³Ô¹ÏÍø, Office of Annual Giving, 1100 Rockhurst Road, Kansas City, MO 64110. Please allow two weeks for processing your request.

Questions? Please contact the Office of Annual Giving at 816-501-4731 or advanceRU@rockhurst.edu.

AuthorizationÌýAgreement for Pre-AuthorizedÌýDrafts

Print Form and Fill Out

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I/we hereby authorize 91³Ô¹ÏÍø to initiate debit entries to my/our bank account indicated below and the financial institution named below, to debit the same to such account.Ìý

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Financial Institution

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City

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State

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Zip Code

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Transmit/ABA No.

(See below for more information)

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Account Number

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Amount to debit per month (on or about the 10th of each month): $________________

Check one that applies:

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â–¢ÌýFor a total pledge of $________________

â–¢ÌýOngoing. I will notify you if and when I decide to change this gift.

Please Attach a Voided Check to this Authorization Form

This authority is to remain in full force and effect until 91³Ô¹ÏÍø receives written notification from me (or either of us) of its termination.

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Name(s)

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Phone Number

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Signed

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Date

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Please note where to find the ABA Routing Number on your check.