|
TERMS OF AGREEMENT I am authorizing Macular Degeneration Research (MDR) to charge my credit card account monthly in the amount of the pledge I have indicated. This agreement will remain in effect until I have given MDR at least thirty (30) days written notice of its termination. A record of each gift will appear on my credit card statement and will serve as my receipt. |
Credit Card:
[ ] VISA
[ ] MasterCard
[ ] American Express
[ ] Discover
| Automatic payment amount: | $___________________________________ |
| Credit card #: | ____________________________________ |
| Security code # (Need Help?) | ____________________________________ |
| Expiration date: | ____________________________________ |
| Signature: | ____________________________________ |
| Date: | ____________________________________ |
Please complete the following information:
| Name: | ____________________________________ |
| Address: | ____________________________________ |
| City/State/Zip: | ____________________________________ |
| Phone: | ____________________________________ |
| Email: | ____________________________________ |
Because this agreement may take a few weeks, please be sure to make this month's pledge contribution with your personal check.. Thank you!
Macular Degeneration Research
22512 Gateway Center Drive
Clarksburg, Maryland 20871
1-800-437-2423