Credit Card Authorization Form

Credit Card Authorization Form
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
Cardholder Name (As shown on card)*

First NameLast Name
Cardholder's Billing Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit Card Type*

VisaMastercardAmerican ExpressOther
Credit Card Number*
Expiration Date*
Month/Year
Payment is for a subscription*

YesNo
Subscription Type *
Amount (Enter amount selected in Subscription Type above)
$ (Dollars)
Subscription Payment Frequency (Enter frequency selected in Subscription Type above)*

MonthlyQuarterly
Today's Date (Subscription payments will start on 1st of the following month)*

MonthDayYear
Date
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.

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.
Cardholder Signature*

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Date*

MonthDayYear
Date
Should be Empty: