Automatic Payment Form

2011 2012 Xtreme Dance Studio Automatic Billing Authorization Autobilling Policy: Registration & 1st Month tuition will be charged directly in the studio (unless we have current information on file already). Tuition will be drafted on the last day of the ensuing month. You will automatically receive $5 off of your monthly tuition payment. The discount does not apply to any partial months and can not be combined with any other offers. An email must be given so you can receive communication for any payments that are not able to be processed. Charges other than tuition and showcase are NOT permitted. LATE FEE: If you card does not process for ANY reason on the 1st attempt, tuition will be charged at the regular amount (no early discount). If not processed by the 9th, the $15 late fee will be applied on the 10th to the regular tuition amount. I agree to the terms above: __________________________________ Date: _______________________

Parents Name Student(s) Name Home Phone email Address

(required for receipt to be emailed)

City

Zip

Auto-billing will begin on the second months tuition. Card Type: VISA ____________ MASTERCARD _______________ DISCOVER ______________

Account Number _________________________________________ Exp. Date______________________ Please use my card to charge Showcase: YES NO Select: pay in 1 payment payment plan (5 = payments) My signature below authorizes Xtreme Dance Studio to charge my account for the current dance season.
Signature Date

Office accounting personnel only Regular Tuition:$_________ Tuition after discount:$______________

Contract Set Up Date First Charge Date

1st Contract Start Date: _________ Last Contract Payment: _________ Contract Amount: __________Desc:_____________ 2nd Contract Start Date: ________ Last Contract Payment: _________ Contract Amount: __________Desc:_____________ Final Payment (June): _________________ Last Month Amount: $___________________ Payment Record Notes (addtl fees charged/card updates etc): ___________________________Date: __________ ___________________________Date: __________ ___________________________Date: __________ ___________________________Date: __________