Credit Card Authorization

I, Card Holder First Name* Card Holder Last Name*, hereby authorize Golden State Youth Orchestra to charge my credit card for the following fee(s):

SYMPHONY ORCHESTRA: Please select any/all that apply:

Symphony Retreat ($542.50) on June 15 and ($542.50) on July 15Symphony Tuition Remainder Payment ($1,110) on Sept. 110 Ticket Digital Card on Aug. 15

CAMILLA KOLCHINSKY ORCHESTRA: Please select any/all that apply:

Camilla Kolchinsky Orchestra Retreat ($670) on June 15Camilla Kolchinsky Orchestra Final Tuition Payment ($1,070) on Sept. 1Camilla Kolchinsky Orchestra Final Tour Payment ($2,125) on Oct. 110 Ticket Digital Card on Aug. 15

GALBRAITH HONOR STRINGS: Please select any/all that apply:

Galbraith Honor Strings September Staccato Camp ($490) on July 15Galbraith Honor Strings Final Tuition Payment ($834) on Sept. 16 Ticket Digital Card on Aug. 1510 Ticket Digital Card on Aug. 15

EL CAMINO WIND ORCHESTRA: Please select any/all that apply:

El Camino Wind Orchestra Final Tuition Payment ($804) on Sept. 110 Ticket Digital Card on Aug. 156 Ticket Digital Card on Aug. 15

CAMERATA ORCHESTRA: Please select any/all that apply:

Camerata Orchestra Final Tuition Payment ($804) on Sept. 16 Ticket Digital Card on Aug. 1510 Ticket Digital Card on Aug. 15

CHAMBER PLAYERS: Please select any/all that apply:

Chamber Players Final Tuition Payment ($741) on Sept. 16 Ticket Digital Card on Aug. 1510 Ticket Digital Card on Aug. 15

Total Amount

Comments - or note the musician name(s)

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Dummy

$0.50 Quantity

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

By signing this form, you give GSYO permission to charge your credit card for the amount(s) indicated on the aforementioned due date(s) or the next business day following the due date(s) [if the due date falls on a weekend]. This is permission for the transactions selected, which will not exceed the total amount indicated, and does not provide authorization for any additional unrelated debits or credits to your account.

If you wish to cancel this authorization, please contact GSYO in writing (by email to deepika@gsyomusic.org) at least one week before a transaction is due to occur.

Signature*

I authorize the Golden State Youth Orchestra to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Credit Card Authorization Form