This Form cannot be submitted until the missing
fields (labelled below in red) have been filled in
Credit Card Authorization Form
Please note that all fields followed by an asterisk must be filled in.
Credit Card Type*
Credit Card Number*
Amount to Charge (USD) $*
Make this an automatic recurring monthly charge (amount to be charged on the 1st of each month)
This is a one time payment (please keep my credit card information on file for future payment options)
I authorize Orlando Premier Music Instruction to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this service in accordance with the issuing bank cardholder agreement. If I wish to cancel a recurring payment, I must notify Orlando Premier Instruction in writing 14 days prior to the scheduled charge date. I authorize Orlando Premier Music Instruction to retain my provided credit card information on file unless otherwise specified.
Please enter the word that you see below.
Parents Night Out
Private Art Lessons and Parties
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