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Brooklyn Center for Rehabilitation
Personal Information
Full Name
*
Address
Zip code
Phone Number
Email Address
*
Transaction Details
$
Amount
*
Residents Name
*
Payment for Month
Pay in Installments
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Recurring Payments
Ongoing
2 Months
3 Months
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Credit Card Details
Pay with Check
Card Number
*
MMYY
*
CVV
?
By clicking this form, you give Brooklyn Center for Rehabilitation permission to charge your account as indicated below. This does not provide authorization for any additional unrelated charges to your account.
Account Holder
*
Routing Number
*
Account Number
*
Choose Account Type:
Checking Account
Savings Account
By clicking this form, you give Brooklyn Center for Rehabilitation permission to charge your account as indicated below. This does not provide authorization for any additional unrelated charges to your account.
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Brooklyn Center for Rehabilitation
1455 Coney Island Avenue
Brooklyn, NY 11230
Tell: 718-252-9800
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
