MAB Pledge FORM Please enable JavaScript in your browser to complete this form.We respect your privacy. Your personal and financial information will be securely stored and used only for donation processing. First Name *Last Name *Phone Number *Email *One Time Pledge?Check the BoxVoid Cheque or Credit Card *SelectVoid ChequeCredit CardClick Here to Donate If payment screen doesn’t display correctly Click Here instead to Donate Pledge Amount *Minimum $10Preferred Debit Date *10th of every month22nd of every monthStarting Month *JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberTerms and Conditions I acknowledge that I have read, understand, and accepted all the provisions contained in the terms and conditions of the Pre-Authorized payment authorization. Signature *Date / Time *Note: • Please attach a void cheque with the pledge form and mail the signed form and void cheque to Brantford Mosque 192 Greenwich Street, Brantford, ON, Canada, N3S 2X6. Or email to. info@brantfordmosque.ca. Upload Void Cheque Click or drag a file to this area to upload. Consent for MAB membershipCheck Box if you like to become a MAB member• The Membership application will be subject to review and approval of MAB Membership Administrator. If any issues or concern will update you within 60 days. Please read and agree by selecting the box against each statementI agree solemn undertaking to abide by the by-laws, aims and objectives and code of conduct of the MABI have no criminal recordI hereby declare that I am a Muslim who bears witness that Allah is One and Prophet Mohammed (Peace be upon Him) is the last prophetWant to Add Family MembersYesNoFill-in the table and the next section, In case if additional family members living at the same address will like to be part of MAB, please check add member and complete the form and provide the copy of government issued photo ID of family members Add member1Add Family MemberFirst Name *Last Name *Birthday *Gender *Email *Phone *ID *Add member 2Add a memberFirst Name *Last Name *Birthday *Gender *Email *Phone *ID *Add member 3Add a memberFirst Name *Last Name *Birthday *Gender *Email *Phone *ID *Add member 4Add a memberFirst Name *Last Name *Birthday *Gender *Email *Phone *ID *Submit
