Payment Authorization Form
If you want to update your payment on record, please fill out the below Recurring Payment Authorization Form.
Student's Name School Name
Schedule your payment to be automatically deducted from your debit or credit card. Just complete and sign this form to get started! Cash or check will not be accepted. All payments must be automatic from your debit/credit card.
Here's How Recurring Payments Work:
Please complete the information below:
I, authorize JM Dance Center to charge my credit/debit cardindicated below for $ in the of each Month for payment of my Dance Classes.I, authorize JM Dance Center to charge my credit/debit card.indicated below for $ only for the first month (this amount includes first month & registration fee)
Exp Date: / CCV
I, understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify JM Dance Center in writing of any changes in my account information or termination of this authorization at least 10 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that JM Dance Center may at its discretion attempt to process the charge again within 30 days and agree to an additional Fee charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company, so long as the transactions correspond to the terms indicated in this authorization form.
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Signed by Jeniffer Munives
Signed On: March 2, 2023
If you have questions about the contents of this document, you can email the document owner.
Document Name: Payment Authorization Form
Agree & Sign