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Credit Card Payment Form Charger Kids Club

Dassel-Cokato Community Education l 4852 Reardon Ave SW, Suite 1400 l Cokato, MN 55321 l 320-286-4120 I hereby authorize Community Education to debit my credit card/bank check card for my Charger Kids Club payment each month. I understand that my account will be debited at the beginning of each month (September-May). I have the right to cancel this agreement at anytime, but also understand that payment must be made by check, money order or cash by the 1st of each month if I decide to cancel this authorization form. A receipt will be available upon request each month showing that the credit card/bank check card transaction has taken place. Please complete the following:

Child’s Name: _______________________________________________________________________ Cardholder's Name: __________________________________________ Phone: __________________

Mailing Address: _____________________________________________________________________

City: _____________________________________ State: __________ Zip: ____________________

Please circle:

Visa

Mastercard

Discover

Card Number: _______________________________________________________________________

Expiration Date: _______________________________________ 3 Digit Signature Code: __________ ______________________________________________ Signature

___________________________ Date

(For Office Use Only)

q

September

____________________

q

February

____________________

q

November

____________________

q

April

____________________

q

q q

October

December January

____________________

____________________

____________________

q

q

March May

____________________

____________________

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