Please enable JavaScript in your browser to complete this form.Name *FirstLastWhat would you like your WDRT total monthly donation to be? *$5/month$10/month$15/month$20/month$25/month$50/month$100/monthOtherEnter the amount you would like to donate each month *Do you need to update your contact information?YesNoAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Do you need to update your bank account information?YesNoName on Account *Bank Name *Account Number *Routing Number *Account Type *CheckingSavingsWould you like a thank you gift? *YesNo thanks, give all my money to WDRTWhat would you like? *WDRT T-Shirt (Donations of $5/month or more)WDRT Hoodie (Donations of $10/month or more)What size? *SMLXL2XL3XLHow would you like to receive your gift? *Pickup (Preferred)MailWould you like a tax receipt? *YesNoAnything you'd like to share with us?SignatureI 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.Let's just make sure you're human... *What is 11+3? Submit