Credit/Debit Card Draft Form

Donor Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Phone*
Credit/Debit Card Information
Type of Card*
- Visa
- Master Card
- American Express
- Discover
Card Number*
Expiration Date*

Month and Year
Authorization Code*
3 or 4 digit code found on back of card
Name as it appears on card*
First Last
Date for draft to occur*
Frequency of Gift*
- Monthly
- Quarterly
- One-Time Gift
Amount to draft*
Authorization Agreement
I authorize Welch College to charge my credit/debit account each month the amount shown above (this includes my authorization for Welch College to reverse any charges made in error). This authority will remain in effect until I give written notice to cancel it. I understand that all changes of status to this agreement take 3 to 6 weeks to be processed.
*
Name*
First Last
Today's Date*
Month
Day
Year

We’re here to help.

Mike Edwards
Director of the Annual Fund
Call: 615-844-5000
Fax: 615-844-5004
Email: mike.edwards@welch.edu

Derek Altom
Executive Assistant for Institutional Advancement
Call: 615.844.5232
Fax: 615.844.5004
Email: daltom@welch..edu