Campus After School Program

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

Child's Name *

Full Name *

authorize Campus ASP Inc. to automatically charge my credit card

account indicated below for

Amount *

on the 1st of every month.

Billing Address *

Billing Address

City

State/Province

Zip/Postal

Account Type *

Visa

Mastercard

Amex

Account Number *

Cardholder Name *

Expiration Date *

CVV2 (3 digit number on back of Visa/MC)

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

Signature *

Date