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Financial Counseling Program Enrollment Form

Contact Information
*First Name:
Middle Name:
*Last Name:
*Address:
Address 2:
*City:
*State:
*Zip:
*Area Code + Phone:
Email:

By entering your e-mail address here and checking the box below, you authorize Stacey Braun to provide materials regarding Stacey Braun and its financial counseling services by e-mail. Please note, no confidential information will be sent by e-mail. You may withdraw consent for e-delivery or request paper copies of any documents at any time for no additional charge.
*Birth Date:        
*NYSUT Member ID:
Financial Counseling Program Options
*Select one:
Credit Card Information
* Credit Card Type:
*Card Number:
3 Digit Security Code (from back of card)
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*Expiration: Month       Year 
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