WORT 3500 CLUB

Below is the 3500 Club enrollment form. Please print and fill-out completely. Keep the bottom portion for your records. You'll need to send us the form with a voided check or deposit slip. You can also stop by the station and drop it off. Our address is 118 S. Bedford St., Madison, WI 53703. Please indicate whether you prefer to have your donation deducted on the 1st or the 15th of each month by checking the appropriate space. It does take our credit union, Heartland, around 10 days to process your enrollment.

AUTHORIZATION FOR AUTOMATIC DONATION

I authorize WORT 89.9FM Back Porch Radio Broadcasting, Inc. and the financial institution named below to initiate entries to my checking/savings account. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment/donation of any entry by notifying my financial institution 3 days before my account is charged.

_____________________________________________________________________
(name of financial institution)(branch)

_____________________________________________________________________
(city)(state)(zip code)

_____________________________________________________________________
(signature)

_____________________________________________________________________
(Name - please print)

_____________________________________________________________________
(Address - please print)

Account No: ___________________________________ Checking ___ or Savings ___

THREE YEAR OPTION: Amount to donate per month: $97.22 Date of withdrawal: 1st ___ or 15th ___
FIVE YEAR OPTION: Amount to donate per month: $58.33 Date of withdrawal: 1st ___ or 15th ___

Financial Institution Routing Number: _______________________________________
(between these symbols |: |: on the bottom left of your check)

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RETAIN FOR YOUR RECORDS

On ______ I authorized ___________________________________________
(date) (company name and dept)

____________________________________________Phone: _______________
(Address)

to initiate electronic entries to my checking/savings account and have agreed to the terms listed on the authorization. I may revoke my authorization with the company at any time by writing to the address above.