MCN Pre-Authorized Debit Agreement

Pre-Authorized Debit Agreement

Set up your monthly donation pledge via pre-authorized debit. Please complete all required fields to authorize your recurring donation.
MUSLIM COMMUNITY OF NORTHUMBERLAND Masjid Al-Ghafoor2-277 Division Street, Cobourg, ON K9A 3R2 P: (905) 373 0900
YES, I WANT TO DONATE: MONTHLY PLEDGE
Donation Amount ($)
Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
Province
Postal Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Banking Information (or please attach VOID CHEQUE)
Banking
Branch # (5 digits)
Account #
Signature of account holder
Date

MonthDayYear
Date
ONE-TIME DONATIONS, please e-transfer to: connect.mcn@gmail.com
Should be Empty:

Pre-Authorized Debit Agreement