Sustaining Member Form

Print and Send to:

Sisters Of The Road
133 NW Sixth Avenue
Portland, Oregon 97209
Phone: (503)222-5694
Fax: (503)222-3028

YES!  I want to become a Sustaining Member of Sisters Of The Road.  I would like to make a monthly contribution of:

( )$10.00 ( )$20.00 ( )$30.00 ( )$50.00 Other $_____

I authorize Sisters Of The Road Café, Inc. to receive my monthly contribution of $ _______ , which will be deducted from my checking account on the 5th of each month.  My checking account is at: 

Bank or Credit Union:  ______________________________________

Please make out a CHECK, mark it VOID, and attach it to this form.  We must have this to process your contribution.

I understand that this authorization can be revoked at any time by writing Sisters Of The Road, Inc.  I agree to provide Sisters Of The Road, Inc. with 10 days’ written notice of my intention to cancel.

Name ___________________________________________

Signature ________________________________________

Date ______________________________________________

Email ______________________________________________