Credit Card Payment Agreement

Document Sample
Credit Card Payment Agreement Powered By Docstoc
					Name_____________ Inv#_______________ Permit_____________________ Exp. Date_________

             ^----Office Use Only---^                How did you hear about us? [] Internet                   [] Direct Mail

1st Class Driving School, Inc.                                                          [] Yellow Pages [] Other

3550 West 145th St                                                                      [] Word of Mouth

Burnsville, MN 55306

_____________________________________________________________________________
First                                  Middle                          Last Name

_____________________________________________________________________________
Address                                                   City         Zip

DOB______/_______/_______ Home # (_____)______________ Cell # (____)_______________

Email Address (for BTW confirm)_____________________________________________________

1st Class Driving School, Inc. does hereby agree to teach for a fee;___hours (max of 30, min of 6 hours if
under 18) of one-on-one Behind the Wheel (BTW) Instruction to the person whose name and address
appears on this Contract. If said person is a minor child, a parent or guardian must sign this contract for
verification/agreement. If the student does not show, does not have his/her Instruction permit, or cancels
                                       st
a BTW appointment without giving 1 Class Driving School, Inc. a 24-hour notice, the student/parent
will be charged an extra $45.00 for each missed lesson. In the event that a student is unable to finish
class due to sickness or family emergency, they will be refunded the prorated portion of the unattended
class. If the contract expires any unused instruction will be forfeited. 1 st Class Driving School, Inc. does
not guarantee a Driver License for any student. This contract expires one year from the date of signature.

Parent/Guardian Signature_____________________________________Date:______________

Student Signature____________________________________________Date:______________

Authorized Personnel Signature_________________________________Date:______________

Amount Paid $_________ Date of Pymt ___________ Pymt Type_________ Balance $__________

******************************************************************** **********************************************

BTW #1                                    BTW #2                             BTW #3

__ Pretrip             __ Parallel Park   __ On Ramp        __ Off Ramp      __ 1way > 1way      __ 2way > 1way

__ Right Turn          __ 90 Deg. Back    __ Clear Inter    __ Big Picture   __ 1way > 2way      __ Freeway

__ Left Turn           __ Hill Park       __ Follow Dist    __ Lane Chngs    __ Clear Inter      __ Space Cushion

__ Stop Sign           __Traffic Light    __ Speed          __ X walk        __ Unmark Lane      __ Observations

__ Clear Inter         __ Lane Chngs      __Blind Spot      __ HELT          __ No Turn on Red   __ Traffic Flow    __ WC


Comments:
                           Credit Card Payment Agreement

Down Payment          $_______
Payment #2            $_______
Payment #3            $_______

I agree to have the above payments charged to the following credit card number based on the
mutually agreed upon dates for BTW as well as the initial payment which will be charged on
___/___/___.

The payments will be charged to the credit card listed below the day prior to the first BTW and
final payment will be charged prior to the day of the second BTW.

Name of cardholder     ___________________________________


Signature             ___________________________________


Date                  _________________

Credit Card Information

Credit Card:           Visa MC
Credit Card Number: ________-_________-_________-_________
Exp Date:              ____________
Security Code:         ____________
Billing address is same as contract info?    Yes No


If no, billing address: __________________________________________________

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:636
posted:10/3/2008
language:English
pages:2
Description: This is an example of credit card payment agreement. This document is useful for creating credit card payment agreement.