The South American Missionary Society (SAMS-USA)
Enrollment for Electronic Funds Transfer
(automatic monthly donations form, your bank account or credit card)

Name       Today's Date(mm/dd/yy)

Address

City State Zip

Phone Email

This authorization to charge my bank or credit card on the 15th of each month shall be the same as if I had signed a check payable to SAMS. This authority is to remain in effect until SAMS receives verbal or written notification of a change. I understand that I am in full control of my payment, and if at any time I decide to make any changes or discontinue the EFT service or credit card billing I will call or write:

SAMS
PO Box 399
Ambridge, PA 15003

(724) 266-0669 (phone)
724-266-5681 (fax)

I will receive a receipt for these automatic monthly donations in the mail, just as if I had sent a check. (If SAMS receives your authorization after the 10th of any month, the automatic withdrawal will begin the following month.)

Checking (Please attach a blank voided check)

BANK NAME

I authorize SAMS to transfer monthly payments from my bank in the amount of
$ . .

Please designate this gift to the following fund(s) beginning the month of :

Great Commission Fund $ .

Missionary (name)     $ .

Other $ .

Signature______________________________________________________________

Credit Card (We can accept MasterCard, Visa, Discover and American Express at this time)

ACCOUNT #       Mastercard Visa

EXPIRATION DATE /

NAME ON THE CARD

I authorize SAMS to bill my credit card on a monthly basis in the amount of
$ .

Please designate this gift to the following fund(s) beginning the month of :

Great Commission Fund $ .

Missionary (name) $ .

Other $ .

Signature______________________________________________________________