Automatic contribution form

I hereby authorize Africa Inland Mission International Inc, P.O. Box 178, Pearl River, NY 10965, USA, to arrange automatic contribution for me on the 15th day of each month, or the first business day thereafter. This authorization shall remain in effect until I notify AIM that I wish to terminate the agreement, which I may do at any time.

Please use my contribution for the following missionaries or projects:

  $

  $

                                Monthly Total  $

(Please attach a list if more space is needed.)

Please charge my bank account (I have attached a voided check or savings deposit slip)

Please charge my credit card (Visa or MasterCard only)

Credit Card Type:    Visa                MasterCard
Credit Card #:      
Expiration Date:     /


To start as soon as I can be enrolled in AIM's program.

To begin in a specific month: ______________

Name:

Address:

City/State/Zip:

Email Address:

Phone (Home/Business.):

Please show signature(s) as required on checks issued against this account:

Signature: ___________________________ Date: __________

Signature: ___________________________ Date: __________