Credit Card Authorization Form 2024-25

Credit Card Authorization Form*

Please complete this form. Your credit card should have an expiry date of August 2025 or later.
STUDENT NAME*

First NameLast Name
Cardholder Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail for billing/receipts*
example@example.com
Credit Card Type*

VisaMastercardAmexDiscover
Billing Zip Code for Credit Card*
*Occasionally the Yeshiva goes on trips and outings (ranging from 1⁄2-day trips to 3-day
trips). In addition, the Yeshiva periodically spends Shabbosim together in locations
throughout Eretz Yisroel. The Talmid’s share of the cost, which you will be informed of,
will be charged to this credit card.
Read our General Information document for more details
Should be Empty:

Credit Card Authorization Form*