CreditDebit-Card-Payment-Form by sdaferv

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									Credit/Debit Card Payment Form

MasterCard, Visa, Switch/Maestro, Visa Delta & AMEX accepted

Participant Details Students’ Name: Payment for: Pre-Ballet Fees (£50)

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(£65)

Pre-Primary/Primary Fees (£55) Grades 2-6, 2 classes per week

Grade 1 Fees/Grades 2-6, 1 class per week Fees (£100) Grades 2-6, 3 classes per week (£140) Grades 2-6, 4 classes per week (£180) Grades 2-6, 5 classes per week (£220) Payee Details Payee/Cardholder’s Name: Payee/Cardholder’s Address:
(please include post code)

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Telephone Number: E-mail Address: Credit/Debit Card Details: Card Type: Card Number: Security Code: Start Date: Issue Number:
(Debit Cards only) (final 3 digits on magnetic strip)

Expiry Date: Amount to be charged:

I authorise Central School of Ballet to charge the above amount to my credit/debit card as detailed.

Cardholder’s Signature: …………………………………………………………………….. Date: ……/……/……


								
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