Recurring Automatic Credit/Debit Charges

Kindly print this form. Once you have completed it, please mail it to:

Friends of St. Paisius Monastery

P.O. Box 1075, Safford, Arizona 85548

Automatic Credit/Debit Charge Authorization

I authorize St. Paisius Monastery to charge my credit/debit card as indicated here:

Frequency (check one): _____Weekly; _____Bi-Weekly; _____Monthly*; _____Bi-Monthly*; _____Quarterly*; _____Annually*

Amount: $_______________

Begin charging my card as of ________/_________ (month/year).

Type of card (check one): _____Visa; _____MasterCard; _____American Express; _____Discover

Card #_________-_________-_________-_________

Exp. _______/________ 3-digit code _______ (from back of card; for AmEx, the 4-digit code)

This authorization is to remain in effect until St. Paisius Monastery has received notification from me of its termination in such time and in such manner as to allow St. Paisius Monastery to act on it.

Name of Cardholder:_________________________________________________

Signature:_________________________________________________________

Date: __________________________________

*Optional: Please charge card around _______________________ (i.e., 1st of the month; 15th of the month; etc.)