P.O. Box 234, Monrovia, CA 91017 - www.foothillsprc.org - (626) 358-2122

Automatic Monthly Donation Authorization Form:

Thank you for your interest in making a recurring donation to Foothills Pregnancy Resource Center. All requested information is required. Upon approval, we will automatically withdraw your donation from your credit/debit card for the amount indicated on a monthly basis. The total charges will appear on the account’s statement. Payment processing dates may vary slightly, but are scheduled for around the 15 day of the month. You may cancel or make changes to this automatic billing authorization by contacting us at any time.

Donor Information:

Credit/Debit Card Information:

Card Zip Code


I authorize Foothills Pregnancy Resource Center to automatically donate the amount listed above on the card provided on a monthly basis. By entering the name, date and authorization pass code below is my digital signature to validate the transaction. (Before pressing “Submit” we recommend printing a copy of this form for your records.)

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Authorization Code