Direct Payment Plan Enrollment Form

Print this form, complete all information and mail with a voided check to the address below.

I authorize the Institute for Culture and Ecology (IFCAE) to initiate a debit for the amount of 

    $10/month  (just 33 cents/day)

    $15/month  (just 50 cents/day)             

    $20/month  (just 66 cents/day) 

    $30/month  (just $1/day)         

    $ _____/month

from my account listed below.  I authorize my financial institution identified below to debit my account 

for these payments.  I understand that I am in full control of my payment, that I have the right

to hold or stop an electronic payment simply by giving my financial institution timely notice, and

that I may revoke this authorization at any time by notifying the Institute for Culture and Ecology.

I will notify the Institute for Culture and Ecology of any changes in the information provided on

this authorization form.

Signature    __________________________________ Date___________________

Name   _____________________________________________________________

Address   ___________________________________________________________

City   ___________________________ State______ Zip______________________

Phone Number   ______________________________________________________

E-mail Address ______________________________________________________

Financial Institution  ___________________________________________________

Address  ___________________________________________________________

City   ___________________________ State______ Zip______________________

Account Number _____________________________________________________

Account Name (on checks)  _____________________________________________

Federal Reserve Routing Number  ________________________________________

Finding the Routing Number on your Check

The Federal Reserve Routing Number is the first number in the lower-left corner of your check.  It appears
between the |: and |: symbols and is usually 9 digits.  Your Account Number is the next number.  It
appears between the second |: and the ||' symbol.  Do not include the Check Number, which follows
the ||' symbol.

Print, complete, and mail this form with a voided check to:

       Institute for Culture and Ecology

       PO Box 6688

       Portland, OR 97228