Registration/Payment Form - Bronx AEP

Thank you for registering for Bronx Alcohol Education Program (AEP). Please complete the below form in full. If you have any questions, please contact Michael Sanabria at (718) 538-7416 or msanabria@nyctasc.org

Contact Information:
Name*
First Last
Phone*
Email*
Date of Scheduled Class:*
MM slash DD slash YYYY
Payment:
Payment Option*
- Pay in full for 5 sessions: $350.00
- Partial Payment: $70.00 (per class)
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Information:
Billing Address*
Street Address Address Line 2 City State ZIP Code
Total
$0.00
SMS Consent
By checking this box, you agree to receive text messages related to conversational purposes, meetings, and follow-up from EAC Network. You may reply STOP to opt-out at any time. Reply HELP to 516-539-0150 for assistance. Message and data rates may apply. Message frequency will vary. This is our Privacy Policy & Terms and Conditions: Privacy Policy
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Registration/Payment Form – Bronx AEP

Contact Information:

Payment:

Billing Information: