Tuition Express Parent Authorization

Location:(Required)

We are excited to offer the safety, convenience and ease of Tuition Express®—a payment processing system that allows secure, on-time tuition and fee payments to be made from either your bank account or credit card.

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT AND CREDIT CARD

I (we) hereby authorize Premier Learning Academy to initiate credit card charges to the below...etc etc etc...credit card type.(Required)

COMPLETE ONE SECTION ONLY

SECTION A (Credit Card)

(4% processing fee per transaction)

Cardholder Name(Required)

Phone #(Required)

Cardholder Address(Required)

Street Address City State ZIP Code

Account Number(Required)

Expiration Date(Required)

Three Digit CC Code(Required)

Cardholder Signature(Required)

Date(Required)

SECTION B (Bank Account)

Your Name

Phone #

Address

Street Address City State ZIP Code

Bank or Credit Union Name

Bank or Credit Union Address

Street Address City State ZIP Code

Routing Transit Number (see sample below)

Account Number (see sample below)

Checking/ Savings

Checking

Savings

Authorized Signature(Required)

Date(Required)

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Tuition Express Parent Authorization

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT AND CREDIT CARD

COMPLETE ONE SECTION ONLY

South Chandler

Queen Creek