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Please fill out the Authorization form

For security purposes, we will contact you by phone to securely collect your credit card information.

CREDIT CARD AUTHORIZATION FORM

Mirloo Music Academy

1353 Marine drive, West Vancouver, BC, V7T1B6

7786889234

mirloomusic@gmail.com

Cardholder Information

Cardholder's Full Name

Card Type (check one)

Visa Card

Mastercard

Card Number (4 last digits)

Phone

Payment Authorization

Purpose of Payment

Payment Options (select one)

Recurring Payment Authorization (Based on a 4-month Contract)

One-Time Authorization

"Please note: By applying for recurring payment authorization, you will receive an invoice for each subsequent month, and the corresponding amount will be automatically charged to your account 10 days prior to the start of the lesson."

Please enter the monthly payment amount as specified in the invoice you received.

If you have selected the one-time authorization method, the amount will be withdrawn only once.

A 2% credit card processing fee applies to card payments.

Amount Authorized

"e.g. CA $192.60"

Authorization Statement

,authorize Mirloo Music Academy to charge my credit card for the amount listed above for the services provided. I understand that I am responsible for ensuring sufficient funds and that this authorization will remain in effect until the end of the contract.

Billing Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Signature

Today's Date

Year

Month

Day

Parent/Guardian Information (if applicable)

Parent/Guardian Name

Student's Name