Sustaining Member Form

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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 ______________________________________________