Program Registration ~ MOHID ©

1 Contact Information

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Last Name *

Phone Number *

Email Address *

Address1 *

Address2

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State *

City *

Zip Code *

Cell Number

3 Payment

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Recurring Start Date*

Number of Months*

For Lifetime

Please note: You will incur a $1 charge if the recurring start date is not current date in order to verify the payment details provided. This charge will not be credited back to your account and you will receive a test transaction receipt for this amount.

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Credit Card Number*

Expiry Date*

CVV Code*

Bank Name

Name on Account *

Account Number*

Routing Number*

Account Type*

Consent * Do you give Mohid Islamic Center consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

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