I (we, if joint account) hereby authorize Girl Scouts of Manitou Council to initiate debit entries to my (our) checking/savings account at the financial institution indicated below.
The amount of the donation will be $ effective (date) . The frequency of the withdrawal of this amount will be: One Time Monthly Quarterly Annually
Name of Financial Institution:
Branch:
City/State/Zip:
Type of Account: Checking Savings
Routing Number:
Account Number:
This authorization will remain in force until Girl Scouts of Manitou Council receives written notification from me (or either of us) of its termination. I (we) may revoke this authorization at any time.
Name(s) (serve as signatures):
Address:
