Payment Authorization

You authorize regularly scheduled charges to your Credit Card/Debit Card. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you, and the charge will appear on your Credit Card/Debit Card Account Statement. You agree that no prior notification will be provided unless the date or amount changes. In this case, you will receive notice from us at least ten days before the payment is collected.

By filling out this form, you authorize the Laity Institute of the Arts to charge your Credit/Debit Card for:

Select amount based on your student(s) tuition.

$110

$120

$140

Enter total for 2 or more children.

First name

Last name

Phone

Credit Card Billing Details

Multi-line address

Country/Region

Address

City

Zip / Postal code

Credit/Debit Card Information

Select Your Credit/Debit Card

Visa

AMEX

Discover

Please charge my card on this day:

Credit/Debit Card Number

Exp Date

Security Code

AMEX

Exp Date

Security Code

Cardholder's Name/Signature

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Thank you