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* 1. With gratitude, I wish to offer my gifts of prayer, thanksgiving, and resources to God.  I wish to enroll in this safe, free program to make regular contributions to Divine Word Catholic Church.  I hereby authorize Divine Word Church of Kirtland, Ohio to initiate debit entries to the following account:

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* 2. I agree the following amount shall be debited:

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* 3. Please debit my account as follows: 

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* 4. Bank Name:

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* 5. Bank Address:

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* 6. Bank Transit - ABA Number (9 digits):

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* 7. Re-enter Bank Transit - ABA Number (9 digits):

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* 8. Bank Account Number:

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* 9. Re-enter Bank Account Number:

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* 10. I agree that this authorization is to remain in effect until Divine Word has received written notification at least ten (10) business days in advance of the desired termination date.

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* 11. Name

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* 12. Date

Date

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* 13. Additional Comments/Instructions, if needed:

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