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Name:  
Billing Address:  
City:  
State:   Postal Code:  
E-Mail:   (for invoicing purposes)
Daytime Phone:   Evening Phone:
SS #: (optional)
 

This is my first time enrolling in Temple of the Goddess Automatic Gifting Program.

I have participated in Temple of the Goddess Automatic Gifting Program in the  past.  My previous plan ended around (mon/day/yr)

 

As my financial pledge to Temple of the Goddess, I hereby authorize Temple of the Goddess to enroll me in the Automatic, Continual Gifting Program and to invoice me for the amount designated below. 

 

I would like to be invoiced: 

 

Amount to Invoice:

 

I request that invoicing begin on (mon/day/yr):  
(Date must be at least 5 business days after enrollment.)

 

  This authority is to remain in full force and effect until Temple of the Goddess has received written notification of its termination from me in such time and in such manner as to afford Temple of the Goddess a reasonable opportunity to act on it, such time to be not less than five (5) business days prior to the next scheduled transaction.