MCQC Donation Pledge Form

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Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com

3 Payment Options Below

Cash / Check / Automatic Bank Withdrawl
Option #1 & #2 Cash / Check

Please send Cash / Check to MCQC, Mohammed Azam MCQC Treasurer
Muslim Community of the Quad Cities 2115 Kimberly Rd, Bettendorf, IA 52722
Option #3 Automatic Bank Widthdrawl Authorization
If you choose Automatic Bank Widthdrawl, MCQC Treasurer will contact you to arrange filling out and signing the ACH Form.

Please DO NOT ENTER your Bank Account & Routing Information here.
Date of Withdrawal

1st of the Month15th of the Month
Requested Start Date

MonthDayYear
Date
I, the undersigned, hereby authorize ACH transaction to be initiated and processed to the account of the Muslim Community of the Quad Cities (MCQC). I, further authorize MCQC to release information about my account to another institution to carry out instructions for ACH transfer This authorization shall remain in effect until I notify the MCQC in writing at least ten (10) business days before the ACH transfer is initiated.
ACH Signature
Sign First and Last Name for ACH Authorization

Signature and Date:
Donation Signature*
Sign First and Last Name for Final Approval of Donation
“…and whatsoever you spend in His (Allah) cause. He replaces it: for He is the best of those who grant sustenance.” Quran 34:3 visit us @ www.mcqc.org
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