Recurring Gift Form - Belmont University

Recurring Gift Form
Electronic Funds Transfer Authorization
Recurring gifts are a safe and convenient option for supporting Belmont University while minimizing
administrative expenses. Your monthly contribution is automatically transferred from your checking
account or billed to your credit card. All gifts are processed around the 15th of each month and
appear on your checking account or credit card statement. You may change or cancel your payments
at any time by notifying Belmont University in writing.
Donor Information
Name:
Address:
Address:
City/State/Zip:
Cell Phone:
Home Phone:
Email:
Gift Information
Please contact Belmont University with any questions concerning designation options. The following amount(s) will be
automatically charged to your credit card or bank account on a monthly basis:
Monthly Amount 1: $
Gift Designation:
Monthly Amount 2: $
Gift Designation:
Agreement for Credit Card Contributions
I authorize Belmont University to charge the amount(s) indicated above, on or around the 15th of each month, to the
following debit/credit card account. This authorization shall remain in effect until I notify Belmont University in
writing or by email at [email protected]
Card Type: ☐ Visa
☐ Mastercard
☐ American Express
☐ Discover
Credit Card #:
Exp:
Security Code:
Signature:
Date:
Agreement for Automatic Bank Drafts
I authorize Belmont University to automatically withdraw the amount(s) indicated above, on or around the 15th of
each month, from the following checking account. This authorization shall remain in effect until I notify Belmont
University in writing or by email at [email protected]
Bank Name:
Bank Address:
Routing Number:
Account Number:
Driver’s License #:
Driver’s License State:
Signature:
Date:
FOR BANK ACCOUNT WITHDRAWALS
PLEASE ATTACH VOIDED CHECK HERE
Return this form to: Belmont University  Office of Development  1900 Belmont Blvd  Nashville, TN 37212