AUTO-PAY CREDIT CARD INFORMATION & AUTHORIZATION FOR TUTORING SERVICES

Customer Name ______________________________________________________________

Street Address ________________________________________________________________

City, State, Zip ________________________________________________________________

Contact Name _________________________________Phone#__________________________

I hereby authorized Education Station to charge my (please check one)

____Visa ____MasterCard ____Discover

Credit Card #:___________________________________________Exp.Date________________

Cardholder’s Name (as it appears on credit card):______________________________________

Billing Address (address your bill comes to):___________________________________________

City, State & Zip Code:____________________________________________________________

By signing below, I authorize Education Station to automatically charge my credit card for each month for the agreed upon fees in relation to tutoring services provided.

By signing this section I hereby verify that the information provided herein is true and correct. I understand that I will need to contact Education Station in writing if I would like my credit card to be deleted from the above company file. Please note a new form must be completed for Credit Card changes such as a new # or exp date.

Cardholder’s Signature:_______________________________________Date__________________

Cardholder’s Printed Name:____________________________________Date__________________

Rules and Policies for Auto-Payment

Monthly Payments:

- This payment agreement is for tutoring services only.

- Your child’s tutoring fees will be charged to the credit card account indicated on the 1st of each month.

- If, at any time, you no longer want to participate in the credit card automatic payment program you need to notify Education Station by completing the Automatic Credit Card Payment Agreement Cancellation form which will be supplied on request by the 25th of the month for monthly payments.

- I understand that the credit card account indicated above will continue to be charged until I submit written notification that I no longer wish to participate in the credit card automatic payment plan.

By signing this agreement, you agree to the above rules and polices regarding the credit card automatic payment program at Education Station.

Signature __________________________________________________ Date____________________________