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Authorize a One-Time Payment
12
Questions
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1
Account Name
*
This field is required.
Parent
Name - See Pink Sheet for this name.
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2
Student Name(s)
*
This field is required.
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3
E-mail
*
This field is required.
To receive a copy of this submission, enter email address.
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4
I received an INVOICE
Yes
No
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5
Date to Process
*
This field is required.
Date
Month
Day
Year
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6
Amount to Process
*
This field is required.
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7
Reason for Payment
Please give a brief description and reason for the payment.
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8
Type of Card
Visa
MasterCard
Discover
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9
Last 4 Digits on Card
*
This field is required.
Card must already be on file with Zion.
Only the Last 4 Digits on the card
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10
Zip Code
Address Postal ZIP Code (5 digits)
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11
Signature
*
This field is required.
My signature authorizes Zion Academy of America to process my payments as scheduled. I certify that I am the authorized cardholder, and I have full authority to make purchases on behalf of the account listed. I understand payments are non-refundable and non-transferrable. The information provided is accurate and complete.
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12
I'm not a robot...
*
This field is required.
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