Monthly Giving Form

Accuracy in Academia (AIA)

Monthly Giving Credit Card Authorization Form

Name as it appears on the credit card:

_____________________________________________________________________________

Credit Card Type (please circle one):             VISA,  MasterCard, or  Discover Card

Card Number___________________________________ Exp. Date _______________________

CVV number ______________________     (last 3 digits on signature panel on back of the card)

Amount of Contribution each month:  _______________________________________________

Name   ________________________________________________________________________

Address  ______________________________________________________________________

City _________________________________ State ___________________ Zip _____________

Phone Number (_____) __________________________________________________________

Email (Optional) _______________________________________________________________

I hereby authorize Accuracy in Academia (AIA) to charge the amount specified above on my credit card each month.

Signature __________________________________________________________________

Date __________________________________________________________________

Please Check One:

_____  I’d rather receive only one solicitation letter once a year from AIA.

_____  I’d like to continue to receive solicitation letters from AIA on a regular basis.

_____  I prefer to receive update letters by e-mail instead of by postal mail.  I’ve included my email address above.

 

Accuracy in Academia is a 501(c)3 organization.  Donations are tax-deductible to the full extent of the law.