Supporting Membership Donation Form

Supporting Membership Donation by Electronic Check

Please complete this form if you wish to help support our efforts to dispel the myths, superstition and fear.

Thank you and Gentle Breezes!

Name

Address

City
State/Province

Country
Zip/Post Code

Phone
Email Address

Membership Donation Amount:

Electronic Checking Account Draft Info  (United States Only)
This section is not for Debit or Credit Card payments.
All fields are required.
Account Name(s) exactly as they appear on your checks including middle initial if applicable. Name1     Name2
Bank Name: Bank Address:
City: ST: Zip: Bank Phone:
Enter the 9 digit bank routing number followed by your account number (usually 9-14 more numbers)in the box below. We need all these numbers to create a valid bank draft. 9 Digit Routing #:   Acct #: Check #: Driver's License #: Issuing State:

All donations must be in US Dollars!

After completing all the sections above, please click the submit button only once.

     Main Index
© Copyright The Celtic Connection. All rights reserved.

Name
Address
City		State/Province
Country		Zip/Post Code
Phone		Email Address
Membership Donation Amount:
Electronic Checking Account Draft Info (United States Only) This section is not for Debit or Credit Card payments. All fields are required. Account Name(s) exactly as they appear on your checks including middle initial if applicable. Name1 Name2 Bank Name: Bank Address: City: ST: Zip: Bank Phone: Enter the 9 digit bank routing number followed by your account number (usually 9-14 more numbers)in the box below. We need all these numbers to create a valid bank draft. 9 Digit Routing #: Acct #: Check #: Driver's License #: Issuing State:
All donations must be in US Dollars!