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Category	Description
Jumuah Donations	JMIC/ICMC United Eid

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Donation Amount *

Frequency

One Time Monthly

First Name *

Last Name *

Phone Number *

Email Address *

Address1 *

Address2

Country *

State *

City *

Zip Code *

Cell Number

Payment Method

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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*

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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 Jam e Masjid Islamic Center consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

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Is Donation for Event JMIC/ICMC United Eid

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