I, ______________________________, hereby authorize the Jewish Educational Center to charge my

Visa / Mastercard # _____________________________, which expires _________, for the amount of

$____________, on or about (date) _____________.

___________________________ ______________

Signature                                        Date

Please send this form to:

Brian Ness
190 Surrey Road
Hillside, NJ 07205

Fax - (813) 329-5275