Invest in Our Youth Club enrollment form
HANKINSON/MANTADOR DOLLARS for SCHOLARS
Name _________________________________________ Address _________________________________________ City State Zip * ONE-TIME CONTRIBUTION *
[ ] $20 [ ] $50 [ ] $100 [ ] Other $________ Would you like to be contacted annually? YES NO Mail to: Hankinson/Mantador Dollars for Scholars----
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* INVEST IN OUR YOUTH CLUB *
Associate - $50 [ ] Master - $250 [ ] Bachelor - $100 [ ] Doctorate - $500 [ ] Recognition Name _______________________ * SCHOLARSHIP SPONSOR * One-Time - $10,000 [ ] Annual - $5,000+ [ ] Name of Scholarship _____________________
PO Box 272, Hankinson, ND 58041-0272 |
I (we) authorize Hankinson/Mantador Dollars for Scholars (DFS) to initiate debit entries to my (our) checking account for payment. The financial institution named below is authorized to charge these entries to my (our) account.
DEBIT AMOUNT $_________________
FREQUENCY [ ] Monthly Last business day of each month [ ] Quarterly Last business day of March, June, September, December [ ] Annually Last business day of December, each year
_________________________________________________________________ Name(s) _________________________________________________________________ Address _________________________________________________________________ City State Zip _________________________________________________________________ Financial Institution _________________________________ Routing/Transit Number _________________________________ Account Number
Savings ________ or Checking ________ Account Type _______________________________________________________________ Address of Financial Institution _______________________________________________________________ City State Zip
Both DFS and my financial institution have the rights to cancel my use of the Pre-Authorized Debit plan. I will write to DFS if I decide to cancel my use of the Pre-Authorized Debit plan.
X_____________________________________________________________________ Signature as shown on my bank account
______________________________________________________________ Daytime phone number Today's Date |