2023-2024 RCS Credit Card Authorization Form
ROXBURY COMMUNITY SCHOOL | 25 MEEKER STREET | SUCCASUNNA, NJ 07876
P: 973-584-7699 | E: BASES@ROXBURY.ORG | W: WWW.ROXBURY.ORG/RCS

Complete this form to authorize Roxbury Community School to make an electronic payment to your debit/credit card below. By submitting this form you give us permission to charge your account electronically for the amount indicated on or after the indicated date. This is permission is for a single transaction only (as selected below), and does not provide authorization for any additional unrelated debits or credits to your account.
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Cardholder Name (as it appears on card) *
Billing Street Address *
Billing City, State, Zip *
Phone *
Email Address (for all confirmations) *
Please provide your credit card details below
Credit Card # *
CCV (3-4 digit # on back of card) *
Expiration Date (mm/yy) *
Card Type *
Please note the program(s) you are authorizing payment for for this transaction. The program amount and/or balance from your monthly statement will be charged.
If you select the One Time Payment for Monthly Fee you will be charged an additional 3% credit card charge per transaction. Families set up with auto-billing will have this 3% charge waived. Transactions will be processed with 72 hours of submission.

If just registering and it's after the 15th of the month, your 1st auto-billed payment will be made with 72 hours of submission (at time of registration).
Program you are authorizing payment for. *
Please note what DAY OF THE MONTH (ex. 1st, 15th, etc) you would like the charge(s) made to your credit card. *
Dollar amount to be processed (if other than current balance)
Authorizing Payment
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
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