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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