I would like to become a Friend of Safe Places
to help children exposed to violence and abuse find safety and protection, and to help families create homes free of violence and abuse.
THREE PAYMENT METHODS FOR YOUR CONVENIENCE:
1. I have enclosed a personal check made out to
Safe Places.
Other amount $ ___________________
2. I would like to charge my monthly Friends of Safe Places gifts to my credit card.
Monthly Pledge Amount: $ ____________________ (Minimum $10)
I want to charge my contribution to my::
MasterCard
VISA American Express Discover
Credit Card No. _____________________________________________________
Expiration Date: ____________________________________________________
Name as it appears on card: __________________________________________
Signature: ____________________________________ Date:________________
Daytime phone number:______________________________________________
3. I would like to make my monthly contribution by electronic funds transfer from my bank account.
(Please attach your voided check to this form.)
Monthly Pledge Amount: $ _____________________ (Minimum $10)
Date:________________ Signature: ___________________________________
I authorize Safe Places to charge a monthly gift as indicated above.
I understand that a record of each gift will appear on my bank or credit card statement and will serve as my receipt.
This agreement will remain in effect until I have given Safe Places written notice of its termination and allowed sufficient time (at least 30 days) to act upon it.
Name: ____________________________________________________________
Address: __________________________________________________________
City: ______________________________________________________________
State: ___________________________ Zip: ____________________________
Email: ____________________________________________________________
Please mail this completed form to:
Safe Places Business Office
Attention: Friends of Safe Places Coordinator
2607 Lehigh Drive
Little Rock, AR 72204