World Services for the Blind Contribution Authorization Agreement

I hearby authorize World Services for the Blind (WSB) to withdraw funds from my account by initiating debit entries to the financial institution named below. In the event that WSB withdraws erroneously from my account, I authorize WSB to credit my account for the amount erroneously withdrawn. This agreement will remain in effect until WSB receives a written notice of cancellation.

WSB will process your contribution on or around the 25th of each month unless you indicate another date in the form below. For questions, please contact us

Contribution Details
Account Type *
Payment information for chosen method
Please enter your routing number and account number.
Please enter your credit/debit card number, expiration date, and security code.
Signature
Name *
Name
Include full address, city, state and zip code.
By completing this section, I authorize World Services for the Blind to initiate debit entries based upon the above information.
Date *
Date