Automatic Contributions to The Trauma Center at JRI

Please print, fill out and mail the form below with a check marked "VOID" across it to the Trauma Center. Our corporate accounting office will set up an automatic deduction schedule from your checking account at your bank. Please sign and date here to authorize the Trauma Center at Justice Resource Institute to arrange this payment method.

Signature:___________________________

Date:_______________________________

Please check one:

______Catherine Jacobus Endowment Fund - MATCHED

______Training

______Other Trauma Center Programs

Name
Street Address
Town/City
State/Zip Code/Country
Phone (optional)
Email Address
Date of First Transfer
Dollar Amount per Transfer
Frequency of Transfers
Duration of Transfers

Please send your completed form and voided check to:

The Trauma Center at JRI

Attn: Lee Fallontowne, Office Manager

1269 Beacon Street

Brookline, MA 02446

Thank you for your donation!