TRIAD Donor ACH Authorization Form

Page 1

After filling out your personal and bank information in this form, you will be required to submit an E-signature. The E-signature will generate an email confirming your enrollment. You must click on the link in the email for the ACH to be effective. Please allow up to 2-3 business days for our accounting department (finance@triad.earth) to process your request.

Today's Date

Is this form being submitted on behalf of an organization?

YESNO

Page 2

Organization Name

First Name

Last Name

Your title with this organization

Business Phone Number

Your Business Email Address

First Name

Last Name

Phone Number

Personal Email Address

Your Home Address Line 1

Address Line 2

City

State

Postal Code

Your Business Address Line 1

Address Line 2

City

State

Postal Code

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FINANCIAL INFORMATION

Name of Financial Institution

Account Type

Checking AccountSavings Account

Account Number

Routing Number (Note: Confirm you have entered the "ABA" routing number. A bank may use more than one type.

TRANSACTION DETAILS

Amount (Enter U.S. Dollar Amount)

Donation Frequency

Monthly DonationOne-Time Donation

Preferred Transaction Date

5th Day of the Month15th Day of the Month25th Day of the Month

I believe in the work of TRIAD and would like to donate to:

The Greatest NeedField WorkerThe OutpostCommunity Center in ArmeniaTranslation of Biblical Resources into the Languages of the Middle EastSafe House for Middle Eastern BelieversIndigenous Training CenterEmergency Relief for Syria

Name of Field Worker

**NOTE: If you have chosen a recurring donation your first transaction will take place on the first available day per your selected, preferred transaction date.

Contact Information