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			<h1 class="article-header__title js-article-title js-page-title">Chai Club Form</h1>
		
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<span style="color: #996600; font-size: 14pt" id="ms__id151">CREDIT/DEBIT CARD SECURE ONLINE PAYMENT FORM <br>
</span></strong></p>
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<span style="color: #cc3366; font-size: 9pt">
<em>We accept Visa, Mastercard &amp; American Express</em></span></strong></p>
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<span class="style2"><font color="#ffffff">Partnership Opportunities</font></span></p>
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<tr>
<td width="596" height="15" bgcolor="#E7E7CF" colspan="3">In our effort to be inclusive for all income levels, Partnership Opportunities have been designed within a wide range. However, if you are capable, please consider participating at a higher level. This will allow us to cover our expenses and continue to expand our programs, services and long term goals.</td>
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<td width="596" height="15" bgcolor="#F1F1E4"><input type="radio" value="Gold Partnership" name="Partnership" tabindex="75">Gold Partnership</td>
<td width="596" height="15" bgcolor="#F1F1E4">$450 Monthly</td>
<td width="596" height="15" bgcolor="#F1F1E4">$5400 Annually-Includes 4 standard Kiddushim</td>
</tr>
<tr>
<td width="596" height="15" bgcolor="#E7E7CF"><input type="radio" value="Double Chai Partnership" name="Partnership" tabindex="76">Double Chai Partnership</td>
<td width="596" height="15" bgcolor="#E7E7CF">$300 Monthly</td>
<td width="596" height="15" bgcolor="#E7E7CF">$3600 Annually-Includes 3 standard Kiddushim</td>
</tr>
<tr>
<td width="596" height="15" bgcolor="#F1F1E4"><input type="radio" value="Silver" name="Partnership" tabindex="77">Silver Partnership</td>
<td width="596" height="15" bgcolor="#F1F1E4">$254 Monthly</td>
<td width="596" height="15" bgcolor="#F1F1E4">$3048 Annually-Includes 2 standard washing Kiddush</td>
</tr>
<tr>
<td width="596" height="15" bgcolor="#E7E7CF"><input type="radio" value="Chai Partnership" name="Partnership" tabindex="78">Chai Partnership</td>
<td width="596" height="15" bgcolor="#E7E7CF">$150 Monthly</td>
<td width="596" height="15" bgcolor="#E7E7CF">$1800 Annually-Includes 1 standard Kiddush</td>
</tr>
<tr>
<td width="596" height="15" bgcolor="#F1F1E4"><input type="radio" value="Family Partnership" name="Partnership" tabindex="79">Family Partnership</td>
<td width="596" height="15" bgcolor="#F1F1E4">$72 Monthly</td>
<td width="596" height="15" bgcolor="#F1F1E4">$864 Annually</td>
</tr>
<tr>
<td width="596" height="32" bgcolor="#E7E7CF"><input type="radio" value="Associate Partnership" name="Partnership" tabindex="80">Associate Partnership</td>
<td width="596" height="32" bgcolor="#E7E7CF">$36 Monthly</td>
<td width="596" height="32" bgcolor="#E7E7CF">$432 Annually</td>
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<td width="596" height="32" bgcolor="#E7E7CF"><input type="radio" value="Associate Partnership" name="Partnership" style="width: 19px; height: 20px" size="19" tabindex="80">Partnership</td>
<td width="596" height="32" bgcolor="#E7E7CF">$18 Monthly</td>
<td width="596" height="32" bgcolor="#E7E7CF">$216 Annually</td>
</tr>
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<p><br>
</p>
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<td width="596" height="32" bgcolor="#E7E7CF">Where would you like to see your Partnership?</td>
<td width="596" height="32" bgcolor="#E7E7CF"><input type="radio" value="on" name="Shul Partnership" tabindex="1">Shul Expenses</td>
<td width="596" height="32" bgcolor="#E7E7CF"><input type="radio" value="on" name="Chabad Programming Partnership" tabindex="1">  Chabad Programming</td>
</tr>
</tbody>
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<table width="663" cellspacing="0" cellpadding="2" border="0" style="border-collapse: collapse; font-family: Arial; font-size: 10pt" dir="ltr">
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<span class="style2">
<font color="#ffffff">Payment Information</font></span></td>
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<tr>
<td width="4" height="15" bgcolor="#F1F1E4"> </td>
<td width="118" height="15" bgcolor="#F1F1E4">Please charge my:</td>
<td width="222" height="15" bgcolor="#F1F1E4">
<select name="x_type" tabindex="81">
<option selected value="Please Choose">Please Choose</option>
<option value="Visa">Visa</option>
<option value="Mastercard">Mastercard</option>
</select></td>
<td width="298" height="15" bgcolor="#F1F1E4">
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                <font face="Arial"><br>
<input type="radio" value="12 month installment" name="Payment" tabindex="82">I wish to pay 12 Month Installments</font>                                          <br>
<font size="1">
                  <font face="Arial">You will be charged at the beggining of each month</font>. <br>
<font face="Arial">Begin payments on:</font>                                                        <select name="month begin payments" tabindex="84">
<option selected value="Choose a Month">Choose a Month</option>
<option value="January">January</option>
<option value="February">February</option>
<option value="March">March</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="June">June</option>
<option value="July">July</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="October">October</option>
<option value="November">November</option>
<option value="December">December</option>
</select></font>
              </p>
</td>
</tr>
<tr>
<td width="4" height="15" bgcolor="#E7E7CF"> </td>
<td width="118" height="15" bgcolor="#E7E7CF">Card Number:</td>
<td width="222" height="15" bgcolor="#E7E7CF">
<input type="text" name="x_card_num" required="false" tabindex="85" id="ms__id158"></td>
<td width="298" height="15" bgcolor="#E7E7CF">Name on card <input type="text" name="x_card_num" required="false" tabindex="85" id="ms__id162"></td>
</tr>
<tr>
<td width="4" height="15" bgcolor="#E7E7CF"> </td>
<td width="118" height="15" bgcolor="#E7E7CF">Exp. Date</td>
<td width="222" height="15" bgcolor="#E7E7CF">
<select name="x_exp_month" tabindex="86">
<option selected value="Month">Month</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select><select name="x_exp_year" tabindex="87">
<option value="Year" selected>Year</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
</select></td>
<td width="298" height="15" bgcolor="#E7E7CF">CVC # <input type="text" name="x_card_num" required="false" size="10" tabindex="85" id="ms__id158"></td>
</tr>
<tr>
<td width="4" height="15" bgcolor="#F1F1E4"> </td>
<td width="118" height="15" bgcolor="#F1F1E4"> </td>
<td width="222" height="15" bgcolor="#F1F1E4">
<p align="right">
<font face="Arial">Total Amount to be charged:</font>
              </p>
</td>
<td width="298" height="15" bgcolor="#F1F1E4">
<p align="right">
<input type="text" value="$" name="x_amount" style="width: 88px; height: 22px" required="false" size="11" tabindex="92" id="ms__id161"></p>
</td>
</tr>
<tr>
<td width="4" height="15" bgcolor="#F1F1E4"> </td>
<td width="118" height="15" bgcolor="#F1F1E4"> </td>
<td width="222" height="15" bgcolor="#F1F1E4"> </td>
<td width="298" height="15" bgcolor="#F1F1E4"> </td>
</tr>
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<strong>Additional comments/information: <br>
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