Credit Card Authorization Form Payment Authorization Form Student Name * Primary Contact Email Address * Recurring Charges * You authorize monthly scheduled charges to your Credit Card on the 1st of every month. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your Credit Card Statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 24 hours prior to the payment being collected. I agree Billing Details Billing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Credit Card * Visa MasterCard AmEx Other Cardholder's Name * Credit Card Number * Expiration Date * CVV * Signature * I authorize Level Up Academy to charge my credit card for monthly tuition. Date * MM DD YYYY Thank you!
