Monthly Recurrence

We will use the credit card information you submit below to set up your monthly credit card charges.

Please disregard the Order Summary of $0.00 on the next page - that is not applicable to recurring payments (only applies to one-time payments).

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CVV *

Monthly Recurrence Amount *

Number of charges: *

12 Payments

Indefinitely

Car Information

Car Year: *

Make: *

Model: *

Mileage: *

Amount

Donation Amount: *

Amount: *

CCBC College Course Amount: *

Amount: *

Apply payment toward the following pledge (optional):

Apply payment toward the following pledge:

Apply payment toward the following:

Kaddish & Plaque Amount: *

$600

Kaddish Amount: *

$360

Day of Learning Amount: *

Day of Learning $360

Evening Study Program $180

Annual Lecture Amount: *

Sponsor: $1,000 per couple

Patron: $500 per couple

Additional Donation:

Please note: Orders over $100 will be hand-delivered (orders under $100 will be mailed). Please call Mr. Schmell at: 443-621-0441 with any questions regarding the delivery of your Agudah Scrip.

8th Grade Mishmar *

8th Grade Mishmar ($75)

Contribution Amount: *

Please select the quantity of each denomination of Scrip that you would like to order:

	$0.75 Scrip (Recipient $0.50 / TA $0.25)
	$1.25 Scrip (Recipient $1.00 / TA $0.25)
	$3.00 Scrip (Recipient $2.50 / TA $.50)
	$5.00 Scrip (Recipient $4.00 / TA $1.00)
	$10.00 Scrip (Recipient $8.00 / TA $2.00)
	$18.00 Scrip (Recipient $14.00 / TA $4.00)
	$25.00 Scrip (Recipient $20.00 / TA $5.00)
	$50.00 Scrip (Recipient $40.00 / TA $10.00)

Please select item(s) from the list below that you would like to sponsor:

$36- Disinfecting Wipes for a Class

$50- Face Masks (250)

$100- Hand Sanitizer for a Class for A Week

$180- Plexiglass on Teacher and Student Desks

$180- Student Tablet for Zoom

$360- Student Chromebook

$750- Teacher Laptop

$1800- Sponsor Additional Maintenance and Cleaning Staff

$2500 – Sponsor Additional Hired Nursing Staff

I would like to Specify an Other Amount:

Other Amount

Other Dollar Amount (CSC):

Processing Fee:

Current Total:

$0.00

Designation: *

Please dedicate the learning at Yeshivas Chofetz Chaim - Talmudical Academy on: * +

Hebrew Date (if known):

Designation: *

Please specify Other designation:

Name of Person: *

Dedicated By:

English Name of Deceased: *

Hebrew Name of Deceased (if available):

Hebrew Name of Deceased's Father (if available):

Date of Death (MM/DD/YYYY): * 🛈 +

Approximate Time of Death (please indicate AM or PM):

Your Relationship to Deceased:

Please list the names and complete addresses as well as the relationship to the deceased of the family members who are to receive notice of the Yahrzeit for the late beloved:

Additional Comments:

Personal Information

Student First Name *

Student Last Name *

Title *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Country *

Email Address *

$18	$36	$72	$180	$360
$500	$1800	Other