Fax this form
to: 216-431-3513 or mail to:
The
City Mission 5310 Carnegie Avenue, Cleveland, Ohio 44103
[ ] I prefer to
pay by check
[
] Sign me up for Automatic Bank Transfer
Name _______________________________________________________
Address ____________________________________________________
City ____________________ State ________ Zip _____________
Day Phone __________________________________________________
Count on me for a monthly donation of:
[ ] $10 [ ] $25 [ ] $50 [ ] $100
[ ] Other $_______________
Your Guarantee - You may change or cancel your donation
at any time by contacting The City Mission.
Automatic Bank Transfer
I give my bank permission to transfer the following amount
from my personal account to support the Mission each month
Bank name _________________________________________________
Bank phone number _________________________________________
Bank account number _______________________________________
Make the monthly deduction from my:
[ ] Checking account (enclose a voided blank check)
[ ] Savings account (enclose a savings deposit slip)
I prefer the monthly transfer date of the:
[ ] 5th OR [ ] 20th (check one)
