Direct Giving (ACH) – Be Together

Name *

First

Last

Phone Number Donation

Email *

Phone *

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Bank Name

Routing Number (9 digits)

Account Number

Account Type

Donation Amount (USD) *

Donation Frequency *

Start Date of Recurring Donations *

Authorization Agreement *

I hereby authorize B2gether to initiate recurring ACH debits from my bank account in the amount and frequency indicated above. This authorization will remain in effect until I provide written notice of cancellation.

Signature (Type full name to authorize) *