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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.
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