Personal Information

First Name: _____________________________  Last Name:  ______________________________________

Address Line 1:  ___________________________________________________________________________

Address Line 2:  ___________________________________________________________________________

City:  __________________________________________  State:  ________  Zip Code:  ________________

Phone:  (           ) ___________ - ____________________

Email address:  ___________________________________________________________________________

** Please make your check payable to "Campus Crusade for Christ" and include it with this form.  

**Please mark your check for account number 2767270.

I would like to begin giving $____________ every month from this checking account.  I understand that I will receive a receipt and a new envelope for the next month after my gift is processed. 

I would like to designate this gift of $ ___________ as a special gift right now with this check.

Signature:  _____________________________________