VIRGINIA TECH FOUNDATION, INC. AUTHORIZATION FOR PRE-ARRANGED PAYMENTS (ACH DEBITS)

I (We) hereby authorize the Virginia Tech Foundation, Inc. to initiate debit entries and/or correction entries to our

__ Checking    __ Savings

account (select one)  indicated below at the depository named below, herein after called DEPOSITORY, to debit the same to each account. 
 

___________________________________________ ___________________________________________
DEPOSITORY NAME BRANCH
___________________________________________ ___________________________________________
CITY STATE
___________________________________________ ___________________________________________
BANK TRANSIT/ABA NUMBER ACCOUNT NUMBER

This authorization is to remain in full force until the Virginia Tech Foundation, Inc., has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the Virginia Tech Foundation, Inc. and the DEPOSITORY reasonable opportunity to act upon it. 
 

___________________________________________________ _______________________________
NAMES SOCIAL SECURITY NUMBER
___________________________________________________ _______________________________
SIGNATURE  DATE
___________________________________________________ _______________________________
SIGNATURE DATE
___________________________________________________ _____________ _______________
Address                                                                       City State                       Zip

Amount: $_________ per month  Begin Deduction on ______________(month) 15 28 _________(year)

Desired Club Level: 
Hokie Club _____$100-$249 
O&M Club _____$250-$549 
Bronze Hokie _____$550-$1199 
Silver Hokie _____$1200-$2499 
Golden Hokie _____$2500-$4999 
Platinum Hokie _____$5000 and up

Hokie Representative: Greg Shumaker (22G)

Please attach a voided check (if using a checking account) or a deposit slip (if using a savings account). For security purposes, please do not fax or email this form. Return this form and all attachments to Gift Accounting, VTAF, P.O. Box 10307, Blacksburg, VA 24062. Please contact one of our gift accountants at givetohokieclub@vt.edu or by phone (540) 231-6618 with any questions.