Credit Card Holder Information
Your charge will appear as North Kendall Education Corporation
Front of Credit Card
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Back of Credit Card
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Billing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Amount to be charged
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First Month
Second Month and on
Cardholder Signature
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Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I authorize North Kendall Educational Corporation to charge my credit card above for the agreed upon amount. 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 or in the original enrollment agreement when the student was signed up at Kumon-Kendall North (North Kendall Educational Corporation). If this is a new credit card, replacing the original form of payment on the enrollment form, all original terms continue to apply.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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