5221 Franconia Road, P.O.Box 10074 Alexandria, VA 22310

Tel. 571 575 9500 | 703 608 4344 | 703 835 0825 | 240 750 7487

በሰሜን አሜሪካ በቨርጂንያ ጠቅላይ ግዛት ለተመሠረተው የሐመረ ብርሃን ቅዱስ አባ ሳሙኤል ዘዋልድባ ገዳም የገዳሙ ቦታ ተገዝቶ ራሱን

እስኪችል ለመርዳት በፈቃደኝነት የሚሞላ የአባልነት ቅጽ

Voluntary “Membership Form to Support Hamere Birhan St. Abba Samuel Zewaldeba Monastery

እግዚአብሔር በደስታ የሚሰጠውን ይወዳልና እያንዳንዱ በልቡ እንዳሰበ ይስጥ”፥2ኛ ቆሮ 9፥7

“…God Loves a cheerful giver” 2nd Corinthians 9 : 7

ስም/ Name

አድራሻ /Address

Ci ty S tate Zip Code _

ስልክ ቁ./ Tel. No

ኤሌክትሮኒክ መልዕክት/ E-mail

አባል ሆኜ በየወሩ እከፍላለሁ/Monthly Contribution Payment________________

በሦስት መንገዶች መክፈል ይችላል/Three Ways to make Payment

1. ቀጥታ በገዳሙ አካውንት (Direct Deposit to Church’s account) Preferred Method

2. በገዳሙ ድሕረገጽ - Thru website: http://www.abbasamueleotm.org

3. ስጦታችሁን/ክፍያችሁን በተጠቀሰው ፖስታ ቤት ላኩልን - Mail your Contribution payments to:

Hamere Birhan St. Abba Samuel EOTG

5221 Franconia Road, P.O.Box 10074 Alexandria, VA 22310

ፊርማ /Signature ______________________ቀን / Date ______________________________

“ሰው የሚዘራውን ሁሉ ያንኑ ደግሞ ያጭዳልና፤በገዛ ሥጋው የሚዘራ ከሥጋ መበስበስን ያጭዳልና፥ በመንፈስ ግን የሚዘራው ከመንፈስ የዘላለምን

ሕይወት ያጭዳል።ባንዝልም በጊዜውእናጭዳለንና መልካም ሥራን ለመሥራት አንታክት።”ገላ 6 7-9

Please complete the information below:

I _______________________________________________ authorize Hamere Birhan St. Abba Samuel Ethiopian Orthodox

Tewahedo Monastery to Charge my bank account/Credit Card indicated below for _____________ (Amount) on a monthly basis.

on or after ___________________ (Date). Suggested Date 15th or 30th of each month.

Membership/አባልነት $____________

Pledge/ቃል ኪዳን $ ___________

Donation/ስጦታ $____________

Billing Address _________________________________________Phone# _________________________

City:_______________________________________ ZipCode________________________

Email______________________________

For Check Recurring Payment

Account Type: Checking Savings Please provide a void Check.

Name On Account

Bank Name

Account Number

Bank Routing#

Bank City/State

DL #/Issue & Exp Date:

For Credit Card Recurring Payment

Account Type: Visa Mastercard American Express

Cardholder Name

Account Number

Expiration Date ____________ DL #/Issue & Exp Date: ____________

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) ______

SIGNATURE _______________________________________________ DATE ________________________

5221 Franconia Road, P.O.Box 10074, Alexandria VA 22310.

Tel. 571 575 9500 | 703 608 4344 | 703 835 0825 | 240 750 7487

I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the

case of the payment being rejected for Non-Sufficient Funds (NSF) I understand that St. Abba Samuel Ethiopian Orthodox Tewahedo Monastery may at its

discretion attempt to process the charge again within 30 days, and I agree to an additional $29 charge for each attempt returned NSF, which will be initiated as

a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of

U.S. law. I will not dispute St. Abba Samuel Ethiopian Orthodox Tewahedo Monastery billing with my bank so long as the transaction corresponds to the

terms indicated in this agreement.

By signing this form, you authorize Hamere Birhan St. Abba Samuel Ethiopian Orthodox Tewahedo Monastery permission to debit your

account monthly for the amount indicated on or after the indicated date. You are required to give written notice (10) days prior to the next

payment date if you wish to cancel this authorization.

የባንክና የክሬዲት ካርድ ቀጥታ ክፍያ ቅጽ

Recurring ACH/Credit Card Payment Authorization Form