Mustafa Institute of California

33527 Western Ave.

Union City, CA
www.mustafainstitute.org
Personal Information

Name:

Address:

City/Town: State: ZIP Code:

Email: Phone: ( )
Donation Information

Monthly gift amount: $15 $30 $50 $100 Other: $

Process my donation on the: 1st 5th 10th 15th of every month
This Donation is made by: an individual a business

I prefer to give by: Credit Card (please fill out the credit card section below)
Pre-Authorized Debit (please fill out the pre-authorized debit (PAD) section below)

Credit Card
Card Type: Visa Master Card American Express Discover

Card Number: Expiration Date (mm/yy):

Name on Card: CSC (Security Code):
Billing Address:

Pre-Authorized Debit (PAD)

Please Attach Void Check For Bank Authorization
Your Bank Name: Bank City & State:

Bank’s Routing Number: Account Number:

I hereby verify that the information provided above is known to be true and correct, and I am the authorized signer on
the credit card/ bank account. I hereby authorize Mustafa Institute of California, a nonprofit corporation of California,
to withdraw from the bank account, and/or charge the credit card for the amount indicated above. I also Understand
that I may change or end this pledge at any time with a written notice.

Signature: Date:

For Office Use Only Received By: Date: