Brotherhood Legacy Program Automatic Donation Agreement Form This is your authorization to charge my account on the 1st day of every month, beginning with the month of*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberIn the year of*in the sum of*which will be deposited with Phi Kappa Tau Housing Corporation Beta Kappa Chapter.Name* First Last Email* Phone*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of account*CheckingSavingsName of Financial Institution*ABA / Bank Routing Number*9 digit numberAccount Number*Min 6 digits - Max 17 digits This authority is to remain in full force and effect until Phi Kappa Tau Housing Corporation Beta Kappa Chapter has received written notification from me of its termination in such time and in such manner as to afford a reasonable opportunity to act on it or when Phi Kappa Tau Housing Corporation Beta Kappa Chapter determines it necessary to discontinue the automatic payment program. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of US law. Confirmation By checkign this box I agree to the stated terms. Signature*Placing cursor inside box will turn it into a pen so that you may apply a signature to this form. This iframe contains the logic required to handle Ajax powered Gravity Forms.