Sustainer Increase

Name *

First

Last

What would you like your WDRT total monthly donation to be? *

Enter the amount you would like to donate each month *

Do you need to update your contact information?

Yes
No

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Do you need to update your bank account information?

Yes
No

Name on Account *

Bank Name *

Account Number *

Routing Number *

Account Type *

Checking
Savings

How would you like to receive your gift if you win? *

Pickup (Preferred)
Mail

Would you like a tax receipt? *

Yes
No

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.

Today's Date *

Let's just make sure you're human... *

What is 11+3?