Auto-Recurring Form

Auto-Recurring Payment Authorization Form

The authority you give to charge your account will remain in effect until you notify us to terminate the authorization. If you have any questions, feel free to call Edna at World Renewal Office. 1-800-248-6512 or 317-467-9899.
Name:*
E-mail:
Phone Number*
- Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Donation Destination (Who/what your donation will go to)*
Checking/Savings Account:
Bank Name
Account Number
Bank Routing Number
Bank City and State
Credit Card
Cardholder Name
First Name Last Name
Account Number
Exp. Date
Month Day Year
CCV

Billing Address (if different than above)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I Authorize World Renewal Intl Inc. to charge/debit my account

Check to Authorize
in the amount of $
for payment of my donation on a basis of.

Every 2 weeks Monthly Quarterly Yearly
Should be Empty:

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