New Membership ~ MOHID ©

Primary Member Infomation

First Name *

Last Name *

Phone Number *

Email Address *

Confirm Email Address *

Company Name

Address1 *

Address2

Country *

State *

City *

Zip Code *

Cell Number

Date of Birth

Cell Number*

Note:

Please update your profile by adding spouse and children information in your member portal

Add Family/Group Information

Group Member Type *

First Name *

Last Name *

Phone Number *

Email Address *

Confirm Email Address *

Same as Primary Member

Company Name

Address1 *

Address2 *

Country *

State *

City *

Zip Code *

Date of Birth

Cell Number*

+ Add Another Family/ Group Member

Add Children Information

First Name*

Last Name*

Phone Number

Email Address

Child Year of Birth

+ Add Another Child

Membership Type *

About Membership:

Do you want to signup membership for your family members too?

Yes No

In Case of No, Only Primary Member will be enrolled in Selected Membership Type.

Select Membership Duration

Membership Period(s) Membership For Lifetime

Membership Start Date:

Membership End Date:

Membership Join Date:

Membership Fee Type *

Before submission, please review the provided information to avoid typing mistakes.

Member(s) Information:

Name	Phone	Email	Address	Relation	Gender	Date of Birth	Marital Status

Children Detail(s):

Name	Phone	Email	Date of Birth

Membership Detail(s):

Membership Type:

Validity:

Membership Start Month	Membership Join Date	Membership End Date

Fee Detail(s):

Fee Type	Fee Amount Per Member	No. of selected Periods

Amount Per Member For Selected No. of Periods	Total Members	Total Amount Due

Payment Information:

Total Amount Due

Amount Paying

Recurring Information

Note: Monthly recurring amount is calculated by dividing the Amount Due with Number of Months.

Payment

Payment Method

eCheck/ACH titleIcon

Credit/Debit Card

Name on Credit Card *

Credit Card Number*

Expiry Date*

CVV Code*

Bank Name

Name on Account *

Account Number*

Routing Number*

Account Type*

Monthly Recurring

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.

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

Agree Decline

Since you purchased free Ticket No Payment Required.

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I Accept * Declaration

Central Illinois Mosque and Islamic Center

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Primary Member Infomation

Note:

Declaration

About Membership:

Member(s) Information:

Children Detail(s):

Membership Detail(s):

Validity:

Fee Detail(s):

Payment Information:

Payment

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