Pledge Form - MIA online

Donor Information

First Name (required)

Last Name (required)

Email address (required)

Phone # (required)

Secondary Phone #

Full Address

Address 1 (required)

Address 2

City (required)

Enter City

Postal Code (required)

Province (required)

Monthly Pledge Amount (required)

$25

$50

$100

$250

$500

Other

Enter Amount (required)

Payment Option (required)

Credit

Electronic Automatic Bank Withdrawal

Card Number (required)

Expiration Month (required)

Expiration Year (required)

Bank Name (required)

Bank Address (required)

Account Number (required)

Name of Account Holder(s) (required)

Upload clear photo of void cheque (required)

Browse...

Maximum size 10MB

Agreement

I (we) hereby authorize Manitoba Islamic Association to initiate debit entries to my account indicated above on the 15th day of each month. This authorization is to remain in full effect until Manitoba Islamic Association has received written notification from me (us) of its termination at least 30 days prior to the next withdrawal date. I agree to maintain sufficient collected funds in my account to cover any such debit upon presentation. I confirm that all persons who are required to sign on this bank account have signed below. (required)

I confirm that all persons who are required to sign on this bank account have signed below.

Signature

Donor Name (required)

Donor Name

Type the characters (required)