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 for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.
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Individual Completing Form (First & Last Name) *
Billing Street Address *
Billing City, State, Zip *
Phone *
Email Address (for all confirmations) *
Please provide your credit card details below
Cardholder Name (as it appears on card) *
Credit Card # *
CCV (3-4 digit # on back of card) *
Expiration Date (mm/yy) *
Card Type *
Billing Address *
Billing City, State Zip *
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.
Program you are authorizing payment for. *
Please note what DAY OF THE MONTH you would like the charge(s) made to your credit card. *
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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