Please enable JavaScript in your browser to complete this form.I would like to donate *$5/month$10/month$15/month$20/month$1/day$2/day$3/dayOther How much? ($5/month minimum)Contact InformationName *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Bank InformationName on Account *Bank Name *Account Number *Routing Number *Account Type *Checking SavingsOther InformationWould you like to receive a tax receipt? *YesNoFor donations over $60: Would you like a WDRT T-Shirt?YesNo thanks, give all my money to WDRTWhat size would you like?SMLXL2XL3XLFor donations over $120: Would you like a WDRT Baseball Hat?YesNo thanks, give all my money to WDRTHow would you like to receive it?Pickup (Preferred)MailAnything you'd like to share with us?SignatureI authorize Driftless Community Radio (DCR) to charge my bank account each month for my WDRT Sustaining Membership using the information on this form. I understand this agreement will remain in effect until I cancel it in writing to DCR. I understand my payment will be executed on or around the 15th of each month and that this may vary with weekends and holidays. In the case of a transaction that is rejected for insufficient funds, I understand DCR may attempt to process the charge again within 30 days, and agree to an additional charge for each attempt to cover costs associated with this. I acknowledge that the origination of ACH Recurring Payment transactions to my account must comply with the provisions of the U.S. Law, and I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the agreed-upon terms indicated in this form.By checking this box, I agree to the above. Submit