Donations & Payments ~ MOHID ©

Donations & Payments

Donor Information

First Name: *

Last Name: *

Phone Number: *

Email Address: *

Category:

Address1: *

Address2:

Country: *

State: *

City: *

Zip Code: *

You can help save us on credit card transaction fees by selecting the eCheck/ACH option. Jazak'Allah!

Payment Information

Payment Method: *

Credit Card

Credit Card Type: *

Name on Credit Card: *

Credit Card Number: *

Expiry Date: *

CVV Code: *

Bank Name:

Name on Account: *

Account Number: *

Routing Number: *

Account Type: *

Recurring:

Recurring Start Date: *

Number of Months: *

For Lifetime:

Consent: *

Do you give Islamic Center of Long Island consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

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Donations & Payments

Is Donation for Event:

4th Spring Fundraising Dinner 2018

Category	Memo: *	Amount

Notes: *

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Islamic Center of Long Island

New York

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