Authorize a One-Time Payment

1

Account Name * This field is required.Parent Name - See Pink Sheet for this name.

2

Student Name(s)* This field is required.

3

E-mail* This field is required.

To receive a copy of this submission, enter email address.

4

I received an INVOICE

Yes

No

5

Date to Process* This field is required.

Date

6

Amount to Process* This field is required.

7

Reason for Payment

Please give a brief description and reason for the payment.

8

Type of Card

Visa

MasterCard

Discover

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

10

Zip Code

Address Postal ZIP Code (5 digits)

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.

12

I'm not a robot...* This field is required.