Personal Information

First Name: _____________________________  Last Name:  ______________________________________

Address Line 1:  ___________________________________________________________________________

Address Line 2:  ___________________________________________________________________________

City:  __________________________________________  State:  ________  Zip Code:  ________________

Phone:  (           ) ___________ - ____________________

Email address:  ___________________________________________________________________________

** Please enclose a check payable to "Campus Crusade for Christ" for this month's contribution.  This will ensure that we will have the necessary banking information to begin future transfers and mail it to the address above along with this form.

**Please mark your check for account number 2767270.

Yes!  I authorize my bank to transfer to Campus Crusade for Christ each month the amount shown below.  I understand a confirmation will be sent prior to my first transfer.

Please transfer my gift of $ _________ automatically on the   5th  or  20th of each month (check one).  

Month to begin: __________

Signature:  _____________________________________