EDC CC AUTH FORM (PDF)




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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:






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