Accuracy in Academia (AIA)
Monthly Giving Credit Card Authorization Form
Name as it appears on the credit card:
_____________________________________________________________________________
Credit Card Type (please circle one): VISA, MasterCard, or Discover Card
Card Number___________________________________ Exp. Date _______________________
CVV number ______________________ (last 3 digits on signature panel on back of the card)
Amount of Contribution each month: _______________________________________________
Name ________________________________________________________________________
Address ______________________________________________________________________
City _________________________________ State ___________________ Zip _____________
Phone Number (_____) __________________________________________________________
Email (Optional) _______________________________________________________________
I hereby authorize Accuracy in Academia (AIA) to charge the amount specified above on my credit card each month.
Signature __________________________________________________________________
Date __________________________________________________________________
Please Check One:
_____ I’d rather receive only one solicitation letter once a year from AIA.
_____ I’d like to continue to receive solicitation letters from AIA on a regular basis.
_____ I prefer to receive update letters by e-mail instead of by postal mail. I’ve included my email address above.
Accuracy in Academia is a 501(c)3 organization. Donations are tax-deductible to the full extent of the law.
