Form Test - The Grand Priory of America

Recurring Pentecostal Appeal

Hidden

Date

Member Name

Donation Frequency(Required)

One Time

Recurring

Please note that recurring monthly donations are not available in the month of December

One Time Donation Amount(Required)

$550 - OLJ & AChLJ

$690 - CLJ & ChLJ

$830 - KLJ, DLJ & SChLJ

$900 - KCLJ, DCLJ, ECLJ & GCLJ

Other Amount

Monthly Recurring Donation Amount(Required)

Please enter the amount your would like to make as your recurring donation. This payment will be a recurring monthly payment for 4 months to The AASL Pentecostal Appeal

Please enter the amount your would like to make as your recurring donation. This payment will be a recurring monthly payment for 3 months to The AASL Pentecostal Appeal

Please enter the amount your would like to make as your recurring donation. This payment will be a recurring monthly payment for 2 months to The AASL Pentecostal Appeal

Other Donation Amount(Required)

Total

Total amount to be charged today

This amount will be debited today. This amount will be debited on the same day of the month for the rest of the year. You will receive a receipt for each payment when it is debited from your account.

ACH

Account Number Account Type Routing Number Account Holder Name

Billing Address(Required)

Please enter the address on your credit card statement.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

ACH

Account Number Account Type Routing Number Account Holder Name

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Comments

This field is for validation purposes and should be left unchanged.