Credit Card Authorization Form

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

E-Mail Address*

Street Address*

City*

State/Prov*

Zip/Postal Code*

Home Phone

Cell Phone

Invoice Number*

Credit Card Type*

	Visa
	Discover
	Amex
	MasterCard

Credit Card Number*

Expiration Date*

Amount to Charge (USD) $*

Payment Options*

	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)

Authorization*

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.

Credit Card Authorization Form

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