Sustaining Member

I would like to donate *

How much? ($5/month minimum)

Contact Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Bank Information

Name on Account *

Bank Name *

Account Number *

Routing Number *

Account Type *

Checking
Savings

Other Information

Would you like to receive a tax receipt? *

Yes
No

For donations over $60: Would you like a WDRT T-Shirt?

Yes
No thanks, give all my money to WDRT

What size would you like?

For donations over $120: Would you like a WDRT Baseball Hat?

Yes
No thanks, give all my money to WDRT

How would you like to receive it?

Pickup (Preferred)
Mail

Anything you'd like to share with us?

Signature

I 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.