Campus After School Program

2901 Campus Rd. Brooklyn, N.Y. 11210 (718) 421-7575

Recurring Card Payment Authorization

Sign and complete this form to authorize Campus ASP Inc. to make a recurring monthly charge to your credit card listed below.

By signing this form you give us permission to charge your account for the amount indicated on the 1st of every month.

Please complete the information below:
After School Program Credit Card Authorization
authorize Campus ASP Inc. to automatically charge my credit card
account indicated below for
on the 1st of every month.
Billing Address *
Billing Address

Account Type *

I understand that I am paying a 3% transaction fee each month for the use of my credit card.