Connection Point Payment Form

Membership Office
781 East New York Ave.
Brooklyn, NY 11203
(718) 774-6000

This form only works with English letters.  For Hebrew please call the office.

First Name:*Last Name:*
Email:* Telephone:


Choose Card:*


Card Number:*Name on Card:*

CVS #:*Expiration Date:*


Text to be displayed.*

Please enter the following code into the box provided:

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