Sustaining Membership

I would like to donate ($5/month minimum)

How much would you like to donate per month?

Contact Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Bank Information

Name on Account *

Bank Name *

Account Number *

Routing Number *

Account Type *

Checking
Savings

Other Information

Would you like an annual 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.

Date *

Let's Make Sure You're Human... *

What is 7+4?

Become a Sustainer

Contact Information

Bank Information

Other Information

Signature