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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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* Indicates required question
Name of Youth
*
Your answer
Name on Credit Card
*
Your answer
Card Type:
*
We only accept Visa and Mastercard.
Visa
Mastercard
Credit Card Number
*
Your answer
Expiration Date:
*
Your answer
CVV (3 numbers on the back of your card)
*
Your answer
Billing Address (Please include postal code)
*
Your answer
Phone number
*
Your answer
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:
Your answer
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