Jon Grano

This form gives authorization for funds to be given automatically.

Bethlehem Baptist Church
Automatic Withdrawal Authorization

___New Enrollment  ___Change in Contribution  ___Change in Account

Name: ____________________________________________

Address: __________________________________________

City State Zip: _____________________________________

Phone: ____________________________________________

Email: ____________________________________________ 

Campus: __________________________________________

Date for first contribution: _____________

Date for last contribution: _____________

Fund Designation  

Fill These Cities 25 x '25  $___________/ Month

Helping Hand $___________/ Month

Total $___________/ Month


Frequecy Cycle (check one):

___ Monthly

___ Twice a month (1st & 15th)

___ Weekly

Please attach a voided check or savings deposit ticket of the account number and routing number of the account that will be debited.

I authorize Bethlehem Baptist Church to process debit entries to my account. I have attached a voided check or savings slip. This authorization will remain in effect unit I give a reasonable notification to terminate this authorization.




Send this completed form to:

Steve Walmsley
Financial Secretary
Bethlehem Baptist Church
720 13th Ave. S.
Minneapolis, MN 55415

© 2017 Bethlehem Baptist Church