Program Registration ~ MOHID ©

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

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3 Payment

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.

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Name on Credit Card *

Credit Card Number*

Expiry Date*

CVV Code*

Bank Name

Name on Account *

Account Number*

Routing Number*

Account Type*

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

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MAS Bronx Muslim Center

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Program Information

حلقة الأخوات (Sisters Halakah)

1 Contact Information

2 Add Registrants

3 Payment

Payment Methods

Or

Payment Summary

MAS Bronx Muslim Center

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Program Information

حلقة الأخوات (Sisters Halakah)

1 Contact Information

2 Add Registrants

3 Payment

Payment Methods

Or

Payment Summary

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