Medical Mission Payment Form
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Required Fields
2018 Medical Mission Payment for in-country transportation, hotel stay, three meals/day: Make a Selection Below
Select Number of Nights:
1-Night Full Payment - 1 Person
2-Nights Full Payment - 1 Person
3-Nights Full Payment - 1 Person
4-Nights Full Payment - 1 Person
5-Nights Full Payment - 1 Person
6-Nights Full Payment - 1 Person
7-Nights Full Payment - 1 Person
8-Nights Full Payment - 1 Person
9-Nghts Full Payment - 1 Person
10-Nights Full Payment - 1 Person
11-Nights Full Payment - 1 Person
12-Nights Full Payment - 1 Person
Replacement ID Card: $19 + 3% convenience fee = $19.57
Contact Information
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First Name
Middle Name
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Last Name
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Address
Address 2
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City
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State/Province
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Zip/Postal Code
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Home Phone
Mobile Phone
Work Phone
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Email
Credit Card Transaction Fee
Unless you're paying for a replacement NOAH NY ID card, leave "Yes!" checked below to add 3% up to a maximum of $10 per transaction for the credit card transaction fee.
Yes! I am aware that I am responsible for the credit card Transaction Amount of $200.00.
Check here only if you're paying for a replacement NOAH NY ID card
Credit Card Information
Card Holder Name
Visa
MasterCard
Discover
AmEx
Card Account Number
Expiration Date
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24
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Security Code
The 3 or 4 digit Security Code (CVV2) can be found on the back of your credit card.
For
American Express
, the Security Code (CID) can be found on the front of the card.
Close
Billing Address
Same As Above
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Address
City
State/Province
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Zip/Postal Code
Email
Privacy Policy
We keep your personal information private and secure. When you make a payment through our site, you provide your name, contact information, payment information, and additional information related to your transaction. We use this information to process your payment and to ensure your payment is correctly credited to your account.
Contact Us
: NOAH NY•• PO Box 24702, Brooklyn, NY 11202 •• 914-874-3264 ••
[email protected]
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