Electronic Funds Transfer (EFT) form

Authorization for automatic payments

I (we) hereby authorize Northwestern College of Orange City, Iowa, to make the following transfer of funds:

Gift information

Gift amount($5.00 minimum per transaction)

Effective date

Gift designation(e.g., Northwestern Fund, capital project, scholarship)

Financial institution information

Name

Address

City

State

ZIP code

Routing number (9-digit number)

Account information

Account type

Checking

Savings

Account number

Name(s) on account

Donor information

First name

Last name

Address

City

State

ZIP code

Phone

Email

Signature

By initialing below, I (we) authorize Northwestern College to withdraw my (our) donation on the 20th day of each month until the termination date specified on this form. month. If the 20^th falls on a Saturday or a Sunday, the transaction will occur the Monday after. If you wish to make any changes, you must contact the Northwestern College Advancement Office at least three business days prior to the scheduled transfer.

InitialsYour initials will serve as your signature.

Date