Floral Image - Dallas Credit Card Form

PPG Payment Information

On the first Monday of each month $150 monthly program fee (fee is subject to change based on registration numbers) will be charged to this account, unless a cash payment is provided by that date.
Month to Month Payment
Credit Card Details
Full Card Number
Expiration Date on Card
Example: Month ## / Year ##
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Monthly Payment Amount: $150 beginning September 1, 2025 thru March 1, 2026

I agree and authorize GSL Community Education to charge a monthly program fee in the amount of $150 per month. I also understand it is my responsibility to update this form if there are any account changes to avoid the $30/month service fee for declined transactions.
Printed Name

First NameLast Name
Authorization Signature

Clear
Date

MonthDayYear
Date
Fee is subject to change
Should be Empty:

PPG Payment Information