Brew City Bully Club

Monthly EFT Donation Option
Easy, Fast, Treasured

Member’s Name _____________________________________

Billing Address ______________________________________

                ______________________________________

Daytime Phone Number ______________________________

Withdrawal Date	20th 	
(if Sunday or holiday withdrawal will be the next business day)

Monthly Donation Amount:    $__________   
          (Minimum $10.00 per month)

Please attach a voided check and sign below.

I authorize the Brew City Bully Club to make deductions from my account as ongoing donations to the organization.  I understand I can cancel this authorization at any time with 15 days prior written notice mailed to: Brew City Bully Club PO Box 26041 Wauwatosa, WI 53226.

Signature _____________________________ Date ________