AUTOPAY FORM

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:

First name

Last name

Phone Number

Billing Details

Street Address

City

Region/State/Province

Postal / Zip code

Credit / Debit Card Information

Select Your Credit/Debit Card

Visa

AMEX

Discover

Please charge my card on this day:

Cardholder's Name

Credit/Debit Card Number

Expiration Date

Security Code (CVV)

American Express users the form above can still be used. The placeholder text is an example for 16 digit cards.

Est. 1989

AUTOPAY FORM

Payment Authorization