Credit Card Form
Once you complete this form and submit it, it will go directly to our Tuition Office.   Please feel free to contact Mrs. Maureen Scroope to confirm receipt of the form at 631-587-8000 ext 134. You can also email the tuition Office at tuition@sjbdhs.org.  Please only submit 1 form per family.
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Email *
Student Name: *
please list all students and indicate student by number (1, 2, 3, etc)
Student 1 Grade: *
Student 2 Grade: (if applicable)
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Student 3 Grade: (if applicable)
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Student 4 Grade: (if applicable)
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Parent Home Phone # *
Please include your area code
Parent Cell Phone #: *
Please include the area code
Please type your legal name (Card Holder name) *
This will act as your signature for authorization to apply the card for payment
Enter today's date *
MM
/
DD
/
YYYY
Payment options: *
Choose one. All credit card payments are due on the 20th of each month indicated.
Credit Card Information
Name as Appears on Card: *
Billing Address: *
City, State, & ZIP Code: *
Credit Card Number (no spaces) *
Expiration date *
MM
/
DD
/
YYYY
Your Email Address: *
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