Authorization to Charge Credit Card Monthly

"*" indicates required fields

Student Information

First Name*

Last Name*

Address*

Street Address City State ZIP Code

Phone Number*

Email Address*

Credit Card Information

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

A surcharge fee applies for credit card payments: 3% for Visa and 4% for MasterCard, Discover and American Express. There is no surcharge fee for debit cards.

Authorization Details

Amount to be charged monthly*

Start Date*

End Date*

By signing this form, I authorize Aspen Beauty Academy to charge the above amount to the credit card listed above on the 1st of each month. If the 1st falls on a non-business day, I understand the payment will be processed on the next open business day.

I agree to notify Aspen Beauty Academy in writing of any changes to my credit card information or if I wish to revoke this authorization. I understand that this authorization will remain in effect until the end date unless canceled by me in writing prior to that date.

Acknowledgment and Agreement

Cardholder Signature*

Date*