United States Judo Association Donation Plan

The USJA automatic donation plan assures the success of USJA programs. Each month, your donation is automatically deducted from your bank account or charged to your credit card. It's easy, convenient and is a steady source of income for the United States Judo Association to continue providing service to American Judo.

> IF DONATING BY BANK DRAFT, please complete by printing: 

Bank Name: _____________________________________________________________

Address: ________________________________________________________________

City : _____________________________________  State: _______   Zip: ____________

Name on Bank Account:  ____________________________________________________

Bank Account Number: _____________________________________________________

Bank Routing Code: ________________________________________________________

(Please include a blank voided check or deposit slip for verification) 

> IF DONATING BY CREDIT CARD, please complete by printing:

Credit Card (circle one):        MasterCard               Visa                     Discover 

Card Holder:  _____________________________________________________________
                              (print name as it appears on credit card)

Card Number: __________________________________________  Expires:____________

I authorize the United States Judo Association to initiate a monthly activity authorizing the bank to debit, or credit card company to charge, the above listed account. This authorization shall remain in effect until the United States Judo Association has received, in writing, notice from me revoking this authorization.

Monthly donation: $ _____________ - _________________________________________
                                  (figure amount)                               (print amount)

Signature:   ________________________________________________  Date:__________
                    (Your donation cannot be processed without your signature)

Print your name:   __________________________________________________________

Date of Birth: __________________  USJA Member Number:  _______________________
                       (must be 18 or older)

Fax completed form to USJA: 719-633-4041  
Or mail to: United States Judo Association                     (Phone: 719-633-7750)
                 21 North Union Blvd
                 Colorado Springs CO 80909-5742

Thanks for your support.