| Student Name:: * |
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| Credit Card Type: |
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| Full Credit Card Numbers: * |
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| Expiration Date: * |
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| Security Code (last 3 digits in the back of the card): * |
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| Card Holder First Name: * |
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| Card Holder Last Name: * |
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| Billing Address Street 1: * |
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| Billing Address Street 2: |
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| Billing City: * |
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| Billing Zip Code: * |
(5 digits) |
| State: |
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| Daytime Phone: * |
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| Evening Phone: |
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| Email: * |
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| Date of Charges: * |
First Payment Date for Recurring charges
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Monthly Recurring Charges. Do not check this if this is ONE TIME charge only.
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| Authorized Amount: * |
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| Disclaims:: |
I certify that I am the authorized holder and signer of the credit card reference above.
I certify that all information above is complete and accurate.
I hereby authorize Da Ke American Chinese
Culture Center (DKACCC) collection of payment for all charges as
indicated above. Charges may not exceed the amount listed above in the
"AUTHORIZED
AMOUNT" field. I understand this is only
for up to this amount during
the time period of "DATES OF CHARGES"
referenced above. If additional
charges are going to be authorized a new
form will have to be completed.
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