I would like to contribute $__________ per month.

Name:_______________________________
Address:____________________________
City:________________ State:___ Zip:_____
Phone:___________ Email:______________
Alumni: Yes____ No____ Year_____


I authorize the Wesley Foundation to automatically collect my gift as follows:
 

Bank Account (voided check required)
Name of Bank:_________________________
Account #___________Checking___ Savings___
Bank Routing #:________________________

Credit Card
Visa____Mastercard____American Express____
Credit Card #____________________________
Expiration date_______________

Date of payment: 1st:____ 15th:____
Beginning month:______________________

This is a 12 month commitment. Continue until I cancel in writing:___ Call in 12 months:____
(If no box is checked, the draft will continue until canceled in writing.)

Authorized signature:____________________
Social Security #:_______________________
Date:_______________________


12:15 Club
The Wesley Foundation at Texas Tech
2420 15th Street
Lubbock, TX 79401