Payment Authorization Form

  • Sign and complete this form to authorize MBJCC to charge your EFT or credit card listed below. By submitting this form you give us permission to debit your account as a one-time transaction or to use the below account for future payments, as you indicate. A separate registration form must be completed for program registration or membership enrollment.
  • Payment Frequency

    I give permission to the MBJCC for a one-time use of my payment option or ongoing use of my payment option for future membership or program charges based on the selection below.
  • Payment Method

    Our agency’s preferred method is bank draft EFTs. As an alternative, we will still accept credit card payments, subject to a 3% “Credit Card Convenience Fee”.
  • Bank Draft EFT Details

    If using a credit card, please skip to the Credit Card section below.
  • Credit Card Details

    A 3% convenience fee is charged for all credit card payments.
  • Date Format: MM slash DD slash YYYY