CMWRC - Springfield, VA Chapter

Bank Debit Form

Note: Please Print and then fill it, before submitting with any necessary pledge/void check(s)

Registered Information
Family ID: 
Family Name: 
Email:
Basic Pledge:
Bala Vihar Pledge, if applicable:
Language Pledge, if applicable:
Total Pledge:
Please make check payable to CMWRC and mail along with this receipt to :
Chinmaya Sevak, 3786 Avenel Ct, Fairfax VA 22033.
Are you already contributing through monthly automatic deduction? Yes/No
Monthly Contribution for 2010-11 30/month 101/month

BANK DEBIT AUTHORIZATION
I hereby authorize CMWRC to initiate debit entries for the amount of $101 / $30 every month,starting September 2010 from my Checking account indicated below for credit to the "CMWRC" account with the Washington First Bank. This authority is to remain in full force and effect for a minimum of one year till August 2011. These deductions will continue after August 2011 as support for Mission activities, until revoked in writing. I will notify Chinmaya Mission immediately if there is any change to my Bank information.
Name of Bank: 
Transit/ABA Number:  
Account Number: 
Please attach one of your checks, marked "VOID" for verification of bank particulars.
Signature:  Date: 

For any questions or concerns, please call Murali Kadaveru (703-716-3396) or Krishnan Seshadri (703-266-9541) or email membership@chinmayava.org
We look forward to seeing you at our 2009-10 Bala Vihar session.
Hari OM!