Credit Card Authorization Form

Credit Card Authorization Form

*Note: We recommend filling out forms on computers rather than phones.
Student's Name*

First NameLast Name
Parent/Guardian's Name (If under 18 yrs)

First NameLast Name
Email *
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Confirm authorization to charge for additional studio services + supplies purchased during class*

YesNo
Payment is for a subscription*

YesNo
Subscription Type
Questions or Comments
I, {cardholderName}, as a cardholder, hereby authorize the Raminfard School of Arts (RSA) to charge my credit card for the uses requested above and confirm that the information for the credit card and billing address is complete and accurate.

I also authorize The Raminfard School of Arts to charge this card for any additional services and supplies purchased during class or upon my request.

By continuing my subscription or attendance, I authorize charges to the most current credit card RSA has on file, including any updated cards issued by my bank.

A $15 late fee will be charged to any past due account. This includes accounts that can not be processed due to inaccurate account information or expired cards.

I have been informed that I can cancel the recurring payment at least 15 days before the payment by phone or signing a consent form provided by the merchant company.

*Please check box to the left of "I agree"
Cardholder Signature*

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Date*

MonthDayYear
Date
Should be Empty: