Recurring Credit Card Charge Authorization Form

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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)

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