Associates 4 Associates Fund

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Last Name

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Phone

Address

Address 2

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City

State / Province

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CARD BANK TRANSFER

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MM / YY

CVC Code

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Billing ZIP Code

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By clicking Donate, you authorise RELIEF FUND DONATION to debit the bank account that you connect to for any amount owed for charges arising from your use of RELIEF FUND DONATION’ services and/or purchase of products from RELIEF FUND DONATION, pursuant to RELIEF FUND DONATION’ website and terms, until this authorisation is revoked. You may amend or cancel this authorisation at any time by providing notice to RELIEF FUND DONATION with 30 (thirty) days notice.

If you use RELIEF FUND DONATION’ services or purchase additional products periodically pursuant to RELIEF FUND DONATION’ terms, you authorise RELIEF FUND DONATION to debit your bank account periodically. Payments that fall outside the regular debits authorised above will only be debited after your authorisation is obtained.

Bank Name

Account Type

Account Last 4

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One-timeMonthlyQuarterlyAnnually