Enrollment Form

	Member Enrollment and Authorization Form Return completed enrollment form to the church office, ATTN: Angela Bruton Office Manager or Pastor Tessaro
Complete this section for ALL Enrollments(Please print in black ink)
Check the appropriate box: ( ) New enrollment/authorization ( ) Change in bank account ( ) Change in authorized amount		Last Name		First Name		M.I.
		Mailing Address
		City		State	Zip
		Home Telephone #		Work Telephone #
Donations/payments should be taken from: ( ) Checking (attach a voided check) ( ) Savings (attach a savings deposit slip) Routing Number _________________________________________ *Valid Routing # must start with 0, 1, 2, or 3* Account Number _________________________________________			REQUIRED: I authorize Thrivent Financial for Lutherans and Vanco Services, LLC to automatically withdraw donations/payments from my account. I have attached a voided check or savings deposit slip. This authority will remain in effect until I give reasonable notification to terminate the authorization. Account Holder Signature ______________________________________ Date ________________________
* Attach a voided check or savings deposit slip FOR A NEW ENROLLMENT OR CHANGE IN BANK ACCOUNT ONLY

Complete this section for LutheranCongregation Donations
Congregation Name: Trinity Lutheran Church		Street Address: 1415 S Holland Ave
City: Springfield		State: MO	Zip: 65807
Church Fund Designations: _________General/Operating_________ _____Building/Debt Reduction ________Repair/Restoration _ ___ _________________________________ _________________________________ TOTAL DONATION AMOUNT	Amount Per Donation: $____________ $____________ $____________ $____________ $____________ $___________ (minimum $5)	Frequency of Donation: (Please check only one) ( ) Weekly on Monday ( ) Weekly on Friday ( ) Semi-monthly (transferred on 1^st and 15^th of each month) ( ) Monthly on the 1^st ( ) Monthly on the 15^th Date of First Donation ______________________________
Note: The total amount will be transferred based on the frequency selected.

* REQUIRED * MUST BE COMPLETED BY Congregation / Institution
Congregation / Institution Code 0021178835	Envelope / Student / Participant Number_________	Verifier Initials______

A simple choice; a generous response

ENROLLMENT INSTRUCTIONS:

1. Using black ink, complete the personal information section including name, address and telephone numbers.

2. Indicate whether this is a new enrollment/authorization, a change in amount, or a change in bank account.

3. Indicate the account type, routing number and account number. Attach a voided check or savings deposit slip to the enrollment form for a new enrollment or change in bank account.

4. Sign and date the Account Holder Signature section.

5. Complete the appropriate section with the institution name and address that will benefit from your giving.

For Your Lutheran Congregation Offering:

· Designate which fund(s) your donation should go to and the amount.

· Select the frequency of your offering.

6. Return the completed enrollment form to the Lutheran congregation, school or institution benefiting from your giving.

Privacy / Confidentiality: The Authorization Form on the back is seen by the nonprofit Lutheran organizations enrolled in Simply Giving^® as well as by the Vanco Services employees who process it. In addition, participant name and address information may be provided to Thrivent Financial for Lutherans. Participant information will not be shared with any other organizations.