Credit Card Authorization
Sign and complete this form to authorize Gateway Legacy Christian Academy to make a single or recurring debit to your card listed below.  By signing this form, you grant permission to debit the account for the amount indicated on the assigned date. In order to revoke this authorization, written notice must be received in the office.
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Email *
Student Name *
What is today's date? *
MM
/
DD
/
YYYY
Cardholder's Name (As it appears on the card) *
Type of Credit Card *
Please charge the card listed below as follows: *
Statement:
Please note all monthly payment plans are charged on the 1st of the month or as soon as possible thereafter.  Payments are late and late fees are added on any payment not cleared by the 5th.  Transactions that are declined will be attempted daily until such time as the payment is cleared.  Cards that are declined for more than 4 days in a row will be subject to additional penalty fees.
Please provide your complete billing address as associated with the credit card, including postal code. *
What is your full phone number? *
Card Number *
Expiration Date *
CVC Number (3 digits on back or 4 digits on front if Amex card) *
Agreement
I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above and the submitted payment agreement on file. This payment authorization is for tuition and school-related fees as noted in my student's account. This credit card is valid only for the period indicated above 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. By typing my name below, I am authorizing use of this credit card as indicated above.
Type Full Name as Signature
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