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Credit Card Billing Authorization

Authorization Agreement: 
Directions: Please check the appropriate box according to the form of payment selected ABOVE. Please note ALL private pay clients must fill out a Credit Card Billing authorization form, but it is your choice as to whether you prefer The Language Lounge to automatically bill your credit card for services.

If check/ cash (if in office payment cash is accepted) on a session by session basis was chosen that:

I hereby authorize The Language Lounge to bill my credit card named below for services rendered to my

I understand that payment is to be made for all services on a SESSION by SESSION basis rendered by  by check and/or cash (if in office payment cash is accepted) as chosen as a preferred method of payment above. I understand that I have a grace period of 10 days to bring my account up to date. In the event that there is an outstanding balance and payment has not been received by the 15th of the month for services rendered, I authorize The Language Lounge to bill my credit card for the services PLUS a $25.00 late fee. I understand that The Language Lounge will check my account prior to running my credit card to make sure that there is an outstanding balance and I will receive an invoice and a reminder before my credit card is billed. In the event that there is NOT an outstanding balance The Language Lounge will not be running my credit card. I understand that the undersigned hereby authorizes The Language Lounge to charge the below-referenced credit card for services rendered. In addition, as per the signed financial agreement in the provided Welcome Packet, I understand my credit card will be charged in the event that:
 Proper cancellation procedures are not followed as noted in the Welcome Packet ($25.00
per 30 minute session, $35.00 per 45 minute session, and $50.00 per 60 minute session
canceled)
 If for any reason services are terminated I will be charged for any outstanding balance for
services rendered if arrangements haven’t been made.
 A check is returned for insufficient funds (you will be billed for the full amount + a $25.00
check return fee)
I, the undersigned, further understand it is my responsibility to inform The Language Lounge of any changes to my credit card information including address, zip code, updated expiration dates, account numbers and security codes. I understand I will be responsible for any bank chargeback fees in the event that this information is not kept up to date. I understand that this agreement will remain in effect until such time as I give a written request to revoke this authorization and/or at the time of termination of services and outstanding balances have been collected.

If your preferred form of payment as chosen above is for The Language Lounge To AUTOMATICALLY bill
for services monthly for services rendered the month prior:
I hereby authorize The Language Lounge to initiate automatic billing from my credit card named below for

I authorize The Language Lounge to automatically bill my credit card by the fifth of every month for services rendered the month prior. I understand that The Language Lounge will check my account prior to running my credit card to make sure that there is an outstanding balance. In the event that there is NOT an outstanding balance The Language Lounge will not be running my credit card. I understand that the undersigned hereby authorizes The Language Lounge to charge the below referenced
credit card for services rendered. In addition, as per the signed financial agreement in the provided
Welcome Packet, I understand my credit card will be charged in the event that:
 Proper cancellation procedures are not followed as noted in the Welcome Packet ($25.00
per 30 minute session, $35.00 per 45 minute session, and $50.00 per 60 minute session
canceled)
 If for any reason services are terminated you will be charged for any outstanding balance for
services rendered if arrangements haven’t been made.
I, the undersigned, further understand it is my responsibility to inform The Language Lounge of any changes to my credit card information including address, zip code, updated expiration dates, account numbers and security codes. I understand I will be responsible for any bank chargeback fees in the event that this information is not kept up to date. I understand that this agreement will remain in effect until such time as I give a written request to revoke this authorization and/or at the time of termination of services and outstanding balances have been collected.

Primary Credit card Authorization