Recurring Lesson Application

Country

Billing ZIP

Financial Responsibility/Guardian Phone

AUTOMATIC BILLING INFORMATION *

The Cardholder is the student.

The Cardholder is NOT the student.

Cardholder Phone *

Student Date of Birth *

Financial Responsibility/Guardian Name

Billing City

Card Expiration Year *

Study Options (Automatic Billing Setup Required) *

Mailing City *

Mailing State *

CVV *

STUDENT INFORMATION (Is the Student a minor?) *

Yes - Complete the Student AND Financial Responsibility/Guardian Information section.

No - Complete Student Section then continue to Automatic Billing Information Section

Acknowledgement *

I certify that I have read and understand the Terms and Conditions. I authorize the Damon K. Clark Vocal Studio to make recurring charges to my Credit/Debit Card listed in this contract/recurring debit authorization form, and if necessary, to initiate adjustments for any transactions credited or debited in error. This authority will remain in effect until the Damon K. Clark Vocal Studio has received written notification from me to cancel it. If I wish to cancel this contract and recurring debit authorization, I understand after having read the Terms and Conditions, that notice of my intent to cancel this contract and recurring debit authorization must be submitted via the SUSPEND/CANCEL form on this website at least thirty (30) days in advance of your scheduled payment cycle (Automatic Billing date) which can be found in this contract. If the contract cancellation is not submitted at least thirty (30) days before the next scheduled Automatic Billing date, I am responsible for payment.

Student Email: *

Cardholder Email *

Electronic Signature (Enter Your Full Legal Name) *

Choose an Automatic Billing Date *

Payment Frequency *

Student Full Name *

Financial Responsibility/Guardian Email

Card Type *

Visa

MasterCard

Discover

American Express

Cardholder Name (Exactly as it appears on the credit/debit card) *

Mailing Address (Include Apt/Ste No., if applicable) *

Mailing Zip *

Card Number *

Card Expiration Month *

Billing Address (Include Apt/Ste No)

Student Phone *