RESPONSE FORM TO PARTNER WITH US …

Thanks for your partnership! There are two ways to support us financially:
 Option 1: A One-Time /First Time Gift
 Option 2: A monthly commitment which can take the form of automatic withdrawal
from your bank account or post-dated cheques.
This form can be sent to us via e-mail (paul.mittelstaedt@nlieurope.com) as a scanned attach-
ment or by regular mail to NLI Canada c/o Paul & Claudia Mittelstaedt, 2535 Sunnyhurst
Close, Oakville, ON L6H 7K5

Name __________________________________________ FIRST TIME GIFT MONTHLY GIFT

$200 $50
Address ________________________________________
$500 $100
$1,000 $200
City ___________________________ Prov ___________
$2,500 $300
Other: _________ Other: __________
Postal Code ________________ Phone _____________

Email __________________________________________

PAYMENT OPTIONS
Option 1 – Automatic Deduction (Void cheque attached)
□ I would like a $__________ payment deducted automatically from my Canadian chequing account on the
______(1st or 15th) of each month, beginning ________________.

By signing below, I/We affirm that all persons whose signatures are required to authorize withdrawals from the account
have signed this authorization. I/We agree that the information contained here may be disclosed to the Royal Bank of
Canada as required to complete any pre-authorized debit transaction. This authorization may be cancelled at any time
by providing 10 days written notice to NLI Canada.

Signature(s) for authorization ________________________ ________________________

Option 2 – Cheque
□ I have enclosed ____ post-dated cheques in the amount of $____________ for monthly payments.
□ I have enclosed a cheque for $_____________ for a first time/one-time gift.
Please make cheques payable to NLI Canada

We cannot support you financially at this time, but are committed to regular prayer on your behalf

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Income tax receipts will be issued at year end to the address provided on this form. Spending of funds are directed by
NLI Board approval. Each contribution designated toward an approved project will be used as designated with the understanding
that when any given need has been met, designated funds will be allocated where needed most.