Name on credit card

First Name

Last Name

Student Name(s)

Phone

Card Type

Mastercard

Visa

Discover

Amex

Card Number

Expiration Date

YYYY

Security Code

Zip Code

By typing your name below, you authorize Monmouth Music Academy to charge monthly payments for tuition. You certify that the information submitted in this form is true and correct to the best of your knowledge.

Credit cards are charged one week prior to the first lesson of the month. To discontinue lessons or suspend automatic charges please notify the academy by e-mail one week prior to the first of the month.

Date

YYYY

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