Auto Pay Application

Cardholder Name*
Student Name
Class Day / Time
Billing Address of Cardholder*
Street Address City State ZIP Code
Card Type*
- MasterCard
- Visa
- Discover
- Amex
Card #*
Expiration Date*
Sec Code*
This is to certify that Junior Gym has my permission to automatically charge my card for: (check all that apply)
- Tuition
- Camp
- Private Lessons
- Misc
By clicking the SUBMIT button, I am electronically signing this application for Auto Pay. I hereby, authorize Junior Gym to charge my credit card.*
- I Agree
Electronic signature: Enter Full Name
Date*
MM slash DD slash YYYY
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