Program Registration ~ MOHID ©

Islamic Center of Long Island

Islamic Center of Long Island

835 Brush Hollow Road, Westbury, New York 11590, USA

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1 Contact Information

First Name *

Last Name *

Phone Number *

Email Address *

Address1 *

Address2

Country *

State *

City *

Zip Code *

Cell Number

2 Add Registrants

Primary Contact as First Registrant

Registrant Name*

Email Address

Age

Gender

Choose Program

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3 Payment

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*

Monthly Recurring

Recurring Start Date*

Number of Months*

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 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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Payment Summary

Program Fee

$0

Total Registrants

0

Total Cost

$0