Electronic Check Withdrawal Pledge

Please fill these items in so that we can contact you. (Note: All these items are required)

First Name:
Last Name: 
Street Address:
City: State: Zip code:
Country:
Phone # :
Email address

Please indicate the amount you would like to pledge:
(Standard pledges are $35 for new members, $60, $90, $120, $365, $500, and $1000)

Pledge Amount:

May we thank you by name over the air?

No, I'd rather remain anonymous.
Yes.
Yes, but use the following name on air.
Name to use on air:
Would you like to receive e-mail announcements about WFHB special events and station news?

Yes
No

Any comments or ideas?