Saint Patrick Parish
ParishPay Enrollment Form
PARISH PAY ENROLLMENT FORM
Mandatory field: *
First Name:
*
Middle Name: (Optional)
Last Name:
*
Street address:
*
City:
*
State:
*
Zip:
E-mail:
*
Phone:
*
Monthly amount: $______.00
*
Special Collection Amount (per collection): $_______.00
*
Easter Collection Amount: $_______.00
*
Christmas Collection Amount: $_______.00
*
Chosen Four Digit Pin (personal identification number):
*
Payment type:
*
Checking
Savings
Visa
Mastercard
Discover
American Express
Other Bank account
If using bank account:? ........Routing #
Bank account #
If using credit card:? Credit card #
Name on card:
Expiration date: (mm) __ / (yy) ___
_______________________________________________________
