|
Donation Form-Monthly Giving Name _________________________________________________________ Address _______________________________________________________ City __________________________ State ____ Zip Code _______ Telephone Number ______________________________________________ Email Address __________________________________________________ [ ] I would like to make a monthly gift of $______________ [ ] Please charge my gift to: ( ) Visa ( ) MasterCard Name (as it appears on your card) ______________________________________ Account # _______________________________ CVV# ____ what is this? Exp. Date ___/___ Signature _________________________________ Date __________________ [ ] If you would like to pay by direct debit from your checking account each month, please send a voided check, together with this form to: VIVE, Inc. VIVE, Inc. is recognized as tax exempt under section 501(c)(3) of the Internal Revenue Code, Tax ID #16-1331585. |