EFT Form

Name(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Choose Bank Account:

Checking

Savings

Bank Institution Name

Bank Institution Routing Number

Bank Account Number

Amount Of Recurring Gift:

Total Amout

Projects

Withdrawal Date

3rd of Each Month

18th of Each Month

Gift Designation

By clicking the button below, you agree to the following terms and authorize this AutoGift transaction.

The information provided on this form is my personal checking account information, or I am an authorized user for my company. Synergie Francophone will make a monthly withdrawal from my account of the amount I have specified. The first AutoGift withdrawal will be made on the withdrawal date indicated above of each month and will continue until I request that it stop.

To make any changes, or cancel this payment transaction, e-mail or call 630-221-1980. Cancellation or changes will be effective at the beginning of the next month provided there are a minimum of two business days before the end of the current month.

RECAPTCHA