Recurring Credit Card Charge Authorization Form printable pdf download

SIDE B

Juniata Mennonite School

289 Leonard Hill Road

**See Side A if you want to pay via

McAlisterville, PA 17049

ACH Debit from your checking or savings

(717) 463-2898

RECURRING CREDIT CARD CHARGE AUTHORIZATION FORM

I (we) hereby authorize JUNIATA MENNONITE SCHOOL , to charge the credit card indicated in this

authorization form according to the terms outlined below. I further understand that a 3% transaction fee

will be added per transaction. I understand that this authorization will remain in effect until I cancel it in

writing. I agree to notify JUNIATA MENNONITE SCHOOL in writing of any changes in my account

information or termination of this authorization at least 15 days prior to the next billing date. I certify that I

am authorized user of this credit card and that I will not dispute the payments with my credit card company

provided the transactions correspond to the terms indicated in this authorization form.

______________________________________________________________________________________

(RESPONSIBLE PARTY- PRINT NAME AS IT APPEARS ON CARD)

______________________________________________________________________________________

(STREET ADDRESS)

______________________________________________________________________________________

(CITY)

(STATE)

(ZIPCODE)

______________________________________________________________________________________

(PHONE NUMBER)

(EMAIL)

PLEASE CIRCLE ONE: VISA / MASTERCARD / DISCOVER

ACCOUNT NUMBER___________________________________________________________________________

EXPIRATION DATE______________________________________3 DIGIT CID#_________________________

(FOUND ON BACK OF CARD)

PAYMENT DATE:

PAYMENT FREQUENCY: (Select ONE)

Circle ONE: 5th or 20th

□ Monthly

□Annual

□Semi-Annual

□Other

Month, Year of

(If “Semi-Annual” or “Other” is selected, list months for payments.)

2nd

3rd

4th

5th

6th

1st Payment

PAYMENT TERMS:Total Balance Due: $__________________________________________#

Payments_______________

Tuition Payment: Amount $_________________Add 3% Transaction Fee$_______________per payment

TOTAL SCHEDULED PAYMENT AMOUNT: $__________________________________________

____________________________________________

______________________ /

/_______

(SIGNATURE)

(DATE)

Recurring Credit Card Charge Authorization Form

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