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 T.C.A. District Five Litigation Fund Contribution

For only $50.00 per month you can protect your profession and your practice from those who would take your freedom to practice away from you.  I would like to be a Member of the T.C.A. District Five Litigation Fund by contributing:

□ $100 per month  □ $50 per month     □ $25 per month     □ Other: $____ per month

□ Other: A one time contribution of $___________

Payment Type (check one)

□ Check enclosed: $________ Please make payable to (T.C.A. District 5 Litigation Fund)

□ Visa           □ Mastercard           □ American Express          □ Discover

Card #_________________________    Expiration Date ______________

Card Address ______________________________________________

Name on the Card __________________________________

□ Auto Bank Draft (ACH) Attach a voided check for accuracy.

Name_____________________________________________________________

Address____________________________________________________________

City___________________________ State_____Zip_________________

Phone__________________________Fax__________________________

Email_______________________________________________________

Signature_____________________________________________________

Please mail this form to T.C.A. District Five Litigation Fund, c/o Dr. Ricky Hanks, 11411 East Northwest Hwy.
Ste.  107, Dallas, Texas 75218 or fax this form to (972) 772-4569.

Thanks in advance for all of your support.

Dr. Chad Blackwell
Treasurer of the T.C.A. District Five Litigation Fund

Your authorization will remain in full force and effect until Dr. Ricky Hanks has received written authorization from you that you want to discontinue
your contributions and this notice is in such a manner as to afford Dr. Hanks a reasonable opportunity to act on discontinuing your withdrawals.