New Membership ~ MOHID ©

Primary Member Infomation

First Name *

Last Name *

Phone Number *

Cell Number

Email Address *

Confirm Email Address *

Company Name

Address1 *

Address2

Country *

State *

City *

Zip Code *

Native Country

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 *

Cell Number

Email Address *

Confirm Email Address *

Company Name

Same as Primary Member

Address1 *

Address2

Country *

State *

City *

Zip Code *

Native Country

+ Add Another Family/ Group Member

Add Children Information

Use this section if you want to add (minor) children records. These records will not be added as members in the system.

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	Native Country	Citizenship Type

Children Detail(s):

Name	Phone	Email	Year 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

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 Middletown Islamic Center Inc 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.

Comments

Promotions

Promotion Code Promotional Price Applied

Payment Information:

Total Amount Due

Amount Paying

Recurring Information

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

I Accept Declaration

Middletown Islamic Center Inc

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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

Promotions

Payment Information:

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