Program Registration ~ MOHID ©

Islamic Center of Staten Island

365 VETERANS RD W, Staten Island, New York 10309, USA

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Islam 101

07
JAN

12:00 AM

24
MAR

12:00 AM

Program Fee:

One Time: $300.00

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

Choose Program

Full Name (First & Last)*

DOB (dd/mm/yy)*

What are your goals for the end of the course?*

What made you interested in registerting for this course?*

How did you hear about our program?*

+ Add More Registrants

3 Islam 101 Winter 2024

You can help save us on credit card transaction fees by selecting the eCheck/ACH option. Jazak'Allah!

Payment Method

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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 Islamic Center of Staten Island consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

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Since you purchased free Ticket No Payment Required.

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Payment Summary

Program Fee

Total Registrants

Total Cost

Acknowledgement

By registering , you acknowledge that you will follow all the instructions provided to you by the Masjid for your and other community member's safety

Islamic Center of Staten Island

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Islam 101

1 Contact Information

2 Add Registrants

3 Islam 101 Winter 2024

Payment Summary

Acknowledgement

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