Client Authorization Form — A List Admissions and Tutoring

PAYMENT AUTHORIZATION FORM

The A-List Tutoring Services, Inc. will keep all information entered on this form strictly confidential.
Please choose payment method Credit card or ACH.

CREDIT CARD PAYMENTS

Name that appears on card:

Credit Card Number:

Expiration Date:

Billing Street Address:

City:

State:

Zip Code:

Email

AUTHORIZATION SIGNATURE:

I hereby authorize The A-List Tutoring Services, Inc. to charge my credit card.

DATE:

MM

DD

YYYY

FOR ACH PAYMENT:

Name on account:

Bank routing number:

Bank account number:

Address associated with account:

City:

State:

Zip Code:

Email

AUTHORIZATION SIGNATURE:

I hereby authorize The A-List Tutoring Services, Inc. to deduct my balance from my bank account via ACH for educational services.

DATE:

MM

DD

YYYY