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178 Stelton Rd. Piscataway NJ 08854
(732) 856-1156
Admin@evolutiondancecenter.com
evolutiondancecenter.com
Credit Card Authorization Form
I hereby give Evolution Dance Center LLC authorization to charge my credit card.
Student's Name:
Frequency of Payment:
Type of Card:
Monthly
Visa
Single Transaction
Discover
Mastercard
Name on Card:
Card Number:
Expiration Date:
Security Code:
Billing Address:
City, State, Zip:
Phone Number:
Amount to be charged:
For Following Services:
By signing this form, you authorize to charge your card for the amount listed above.
Signed:
Date:
EDC CC AUTH FORM.pdf (PDF, 168.88 KB)
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