KOM Parent – Student Handbook Agreement Form

Cardholder's First Name*

Cardholder's Last Name*

Cardholder's E-mail*

Cardholder's Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cardholder's Phone Number

Product/Service (Ex: Monthly Tuition Payment)*

Amount authorized*

Card Type*

Card number*

Expiration date (MM/YYYY)*

Recurring Payments Information - I agree for my credit card to be charged the amount above every:*

Week
Month
Quarter

Charge on this date (Ex: first of every month):*

Terms of agreement (For example, cancellations must be received 1 week prior to expected billing date):*

I would like my receipt*

Mailing Address (for receipts)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Authorization to charge credit card*

I agree to the Authorization to charge credit card

I give permission to Clapham Education Group/Charleston Bilingual Academy to charge my card for the following purchases. My card details will be stored in my profile and will only be used for approved purchases.

***I understand the following fees will be charged:

Transfers ACH 1% + 25 cents

Payments by Credit Card 3.4% + 25 cents

Signature

Date