Automatic Credit Card Payment Authorization

I agree to provide the following credit card information and allow the credit card listed below to be automatically charged for the annual registration fee, payment plan service fee, and tuition fees, after all of my registration information has been provided (including signed waivers and agreements) and approved.

Type Full Name

Authorization Signature

Enter date

Credit Card Informaton

Visa

MasterCard

Discover

N/A

Card Holder's Name

Credit Card #

Security Code

Billing Address

Street Address Line 2

City

State

Postal / Zip code

I understand that this authorization will remain in effect until my balance is paid in full (no later than April 1, 2024), and I agree to notify the merchant in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. In the case of a payment being rejected for Non-Sufficient Funds (NSF), I understand that the merchant may at its discretion attempt to process the charge again within 30 days, and agree to an additional $50 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.

Type Full Name

Your Signature

Enter Date