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RENOVARÉ Monthly Donation Enrollment

I authorize Renovaré to (please check one):

___ monthly withdraw the below indicated amount of funds from my listed checking account at the named banking institution, and to credit the same to RENOVARÉ’s bank account.

___ monthly charge the below indicated amount of funds to my listed debit or credit card, and to credit the same to RENOVARÉ's bank account.

Amount of Donation (withdrawal/charge made between 5th and 10th of month):

$___________

Authorized By (please print name) _______________________________

Signed_____________________________________

Date__________ Phone Number____________________ E-mail________________________

Street Address/City/State/Zip______________________________________________________

For Checking Account Withdrawals:

Bank/Depository Name________________________ Branch Phone # _____________________

Branch Street Address/City/State/Zip________________________________________________

Bank Routing # ___________________________ Account #_____________________________
(please include a voided check)

For Debit and Credit Card Transactions:

Cardholder Name _________________________ Card # ________________________________

Exp. (mm/yy) ___________ Card Type (circle one): Visa — Mastercard — AMEX — Discover

Please mail or fax form to:
Renovaré, 8 Inverness Drive East, Suite 102, Englewood, CO, 80112-5624, 303-792-0146 (fax)