www.aspenlaurel.edu301-494-9385 Authorization to Charge Credit Card Monthly "*" indicates required fields Student InformationName*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Credit Card InformationCredit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name Authorization DetailsAmount to be charged monthly*Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY 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 AgreementCardholder Signature*Reset Date* MM slash DD slash YYYY
