Student Name

First Name

Last Name

Name on Card

First Name

Last Name

Card Type

VISA

MasterCard

AMEX

Discover

JCB

UnionPay

Card Number

Please double-check to confirm you have entered the correct digits.

Expiration Date

mm/yy

3 or 4 Digit Security Code

Zip Code

From credit card billing address

Email Address

For receipts

Electronic Signature

By entering my name below and clicking submit, I authorize Paradise Tutors of Naples to charge my credit card above for agreed-upon purchases. I understand that my information will be on file for future transactions until the authorization is cancelled.

Date

YYYY

Credit Card Authorization Form

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