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A contribution of as little as $10 per month, the amount you might spend
on lunch, by credit card or bank draft, can help the animals at HSPC.
The animals we rescue depend solely on the contributions of caring, compassionate animal lovers. We desperately need your help to be able to save the hundreds of cold noses that need your warm heart! Make it easy to give by making a regular monthly contribution to HSPC. The Details - We accept credit cards or we can take deposits directly from your checking or savings account. All thats needed to get set up is your bank account or credit card authorization, along with a canceled check. Please be a pal, and take the time to fill out the agreement form below that best suits you. Send completed form to: Humane Society of Pulaski County 14600 Colonel Glenn Road, Little Rock, AR 72210 We thank you and the animals thank you! Name:____________________________________ Phone:___________________________________ Email:____________________________________ Electronic Bank Draft Direct Debit Agreement Name of Financial Institution: __________________________________________ City:_________________ State:___ Zip:_________ Routing No:_____________________________ Account No:_____________________________ ______Checking or______Savings Please choose amount of Monthly Donation: ______$10______$15______$25_________other Credit Card Information Visa___ MasterCard___ American Express___ Discover___ Other_______ Account No:_____________________________ Expiration Date:___________________________ Please choose amount of Monthly Donation: ______$10 ______$15 ______ $25 ______other Authorization Signature for Credit Card Draft Name as it appears on your credit card: Signed:_________________________ Date:________ |
Authorization
I hereby authorize the Humane Society of Pulaski County (the Company) to initiate direct debit entries to my checking / savings account indicated above and the financial institution above to post the same to such account. This authorization is to remain in force until the Company receives written notice of cancellation from me (see Below). This notice of cancellation must be received at least 30 days prior to cancellation and in such manner as to afford the Company reasonable opportunity to act on it and in no event shall it be effective with respect to entries processed by the Company prior to the receipt of the notice of cancellation. I further authorize the Company to initiate such credit entries to said account as may be necessary to correct any erroneous debit entries previously initiated thereto and I authorize the financial institution to accept and to credit or debit the amount of such entries to my account. All entries initiated hereunder are to be governed in all respects by the rules of the Mid-America Payment Exchange as now or hereafter in effect. __I prefer my account be drafted on or about the 10th of the month __I prefer my account be drafted on or about the 20th of the month Please attach a voided check or this agreement cannot be activated. Cancellation I hereby cancel the authorization for the Humane Society of Pulaski County to originate debit entries to my checking / savings account indicated above. Effective on:_________________________ Signed:____________________________ Date:__________ Humane Society of Pulaski County 14600 Colonel Glenn Road, Little Rock, AR 72210 501/227-6166 · Fax: 501/223-8383 |