CBI Youth Dept. Credit Card Authorization Form 2021-2022
Please complete all fields. Your card will be used for membership dues and future events and activities.
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Name of Youth *
Name on Credit Card *
Card Type: *
We only accept Visa and Mastercard.
Credit Card Number *
Expiration Date: *
CVV (3 numbers on the back of your card) *
Billing Address (Please include postal code) *
Phone number *
I hereby authorize Congregation B'nai Israel Youth Department to charge my card on file for youth membership dues and future events. *
Please provide electronic signature below:
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