CBMC of Tampa (a Non-Profit 501(c)3 Organization)
3302 W. Azeele St.
Tampa, FL 33609
Tel. 813-877-9609 ext. 106 - Sam Ferlita
CREDIT CARD DEBIT AUTHORIZATION FORM
(for Tax Deductible Donations)
If you would like a tax receipt for your giving to CBMC and the Tampa Bay Leadership Prayer Breakfast, you can send
a check to CBMC of Tampa with 2010 Prayer Breakfast written in the memo of your check. They will immediately send
you a receipt for your gift. If you would like to donate by way of credit card, you can copy and paste the form below to MS
Word, fill it out, print it out and mail it to the same address. You can also donate by way of “Make A Donation” that goes
through PayPal and their receipt they send you can be used for tax purposes.
___________________________________________________ (print name as listed on card) hereby authorizes CBMC
of Tampa, to debit the account listed below. *
(Please circle one): Visa (or) MasterCard
# ___________-___________-___________-___________, 3 Digit Security # __________ (see back of card)
Expiration Date: ________/_________ (month / year)
Debit Amount: $_____________.00
Frequency (check one): One-time_______ Monthly Period______________ example: 8 months
Perform Debit Transactions beginning on: ________/________/________(month/date/year) Ending on:______/_____/______
Billing Address (address must match billing address for the account listed above):
City: _______________________ State: ___________ Zip: _____________
Tel:(____)_______-________ Email: ______________________________
Tax Deductible Donations for: 2010 TampaBay Leadership Prayer Breakfast
Fill out complete, and return to CBMC of Tampa at the address or fax listed at the top.
* This authorization can be terminated at any time in writing by the cardholder only.
*8 monthly payments of $131.25 will secure your GOLD sponsorship *7 monthly payments of $150.00
will secure your GOLD sponsorship *6 monthly payments of $175.00 *5 monthly payments of $210.00