Scrip Subscription Form

Scrip Subscription Form

“Scrip” is a monthly cash card that you purchase, which can be used at your choice of Stop & Shop or River Valley Co-op (Northampton and Easthampton). Beit Ahavah receives a 5% rebate on all Scrip purchased. Scrip is a simple way to provide substantial financial support to the congregation without spending any more than you normally spend on groceries or gas. Cards do not expire, can be used for paying for Stop & Shop gas, and given as gifts. Thank you for purchasing Scrip cards here.
Name*

First NameLast Name
Email*
example@example.com
Phone*
413-xxx-xxxx
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I would like to purchase monthly Scrip for: *
In the amount of: *
Additional instructions (optional):
In the event that you would like Scrip for multiples stores in different amounts, please let us know here.
We ask that you purchase Scrip on a monthly basis through the DIRECT WITHDRAWAL program. Please fill out the Direct Payment Authorization form below. This information is private and confidential, and will not be shared with any outside parties. Jotform forms are secure and encrypted.

Unfortunately, we cannot use credit/debit cards for Scrip because the fees are more than half of our Scrip benefit.
Name on Bank Account*
Name of Bank*
Routing Number*
Account Number*
Confirm Account Number*
Payments will be made by automatic bank transaction on or around the 15th of the month, then the Scrip card will automatically be mailed out to the address listed above until Beit Ahavah has been notified of cancellation. Cancellation must be made with 30 days notice. All Direct Payment Authorization will be withdrawn from accounts on or around the 15th of each month unless another arrangement is made with Scrip Coordinator.*

I understand and agree.
I agree that once the subscription has been purchased it cannot be returned unless there are extenuating circumstances that have been discussed and agreed upon by the Beit Ahavah Board of Directors that would allow me to remit my purchase and payment agreement. I agree that upon submitting this form, I am bound by all statements herein.*

I understand and agree.
Beit Ahavah will send by mail. I understand and agree that Beit Ahavah cannot guarantee safe arrival and will not provide refunds if the Scrip is lost in the mail or otherwise does not arrive to the specified address.*

I understand and agree.
Signature*

Clear
Please use your mouse (or finger/stylus on a touch screen) to sign your name.
Date*

MonthDayYear
Please enter today's date.
Thank you for buying Scrip from Beit Ahavah! If you have any questions, comments or concerns, please contact the Beit Ahavah office at info@beitahavah.org or by calling (413) 587-3770.
Should be Empty: