2009-2011 - Santa Monica-Malibu Unified School District
2009-2011 - Santa Monica-Malibu Unified School District
2009-2011 - Santa Monica-Malibu Unified School District
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City of <strong>Santa</strong> <strong>Monica</strong><br />
Youth Office Programs<br />
Automatic Billing Authorization Form<br />
Name of Child _______________________<br />
Program Name_______________________<br />
<strong>School</strong> _______________________<br />
Amount Authorized_____________<br />
Monthly Weekly Bi-Weekly<br />
FROM CREDIT CARD<br />
I authorize you to charge my program fees directly to the credit cards listed below:<br />
Primary Card Account<br />
___________________________________<br />
Name on card exactly as printed<br />
___________________________________<br />
Billing Address for credit card<br />
Secondary Card Account<br />
___________________________________<br />
Name on card exactly as printed<br />
___________________________________<br />
Billing Address for credit card<br />
___________________________________ ___________________________________<br />
City State Zip City State Zip<br />
___________________________________ ___________________________________<br />
Credit Card Number Expiration Date Credit Card Number Expiration Date<br />
____________________________________ ___________________________________<br />
Signature Today’s Date Signature Today’s Date<br />
Bill all charges to the above credit cards.<br />
This authorization is valid until I provide you with a written cancellation.<br />
Visa/Master Card/Discover Only<br />
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