Thank you for choosing to electronically transfer your monthly gift to UNLV using our
Electronic Funds Transfer contribution program. By completing and returning this form,
you will help us more efficiently and inexpensively route your donation to your UNLV
program of choice. The draft will occur on or about the 10th of each month and will reflect
UNLV Foundation on your bank statement.
Special instructions:
For verication of account information, please send a voided check to:
UNLV Foundation, Attn.: Records Department, 4505 S. Maryland Pkwy., Box 451006,
Las Vegas, NV 89154-1006. Once we have received your voided check,
your electronically-transferred gift will go into effect.
For questions regarding the electronic transfer of contributions program, please contact
UNLV Foundation Records department at (702) 895-3641.
First Name______________Middle Name_______________ Last Name_______________
Home Phone________________________ Cell Phone____________________________
Please designate my gift for___________________________________________________
Amount per month $__________
Amount per quarter (Sept, Dec, March, & June) $__________
I (we) hereby authorize the UNLV Foundation, her
einafter called UNLV, to initiate debit
entries to my (our) Checking Account/ Savings Account (select one) indicated below
at the depository financial institution named below, and to debit the same to such account.
I (we) acknowledge that the origination of automatic bank electronic transfers from my (our)
account must comply with the provisions of U.S. law.
Financial institution_______________________________________ Branch___________
City_______________________________________ State____________ Zip__________
Routing/ABA number______________________________________________________
Account number___________________________________________________________
This authorization to draft your acccount will remain in effect until UNLV receives written
notication from you regarding its termination and has had reasonable opportunity to act
upon it.
Name(s) _________________________________________________________________
Date________________________________ Signature ____________________________
Ver 08.14.15
(Please print)
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