Utah Fusion All-Stars Information Packet | Page 11

Fusion All-Stars Credit/Debit
Authorization Form
For FUSION ALL-STAR TEAMS, THIS FORM IS MANDATORY!!!
Please fill this out if you would like be set up on auto-pay. If you choose to have the amount debited on the 20th of
each month, that will pay for the following month. For example, payments debited on May 20th will pay for the
month of June. If you choose to have the mount debited on the 5th of each month, that will pay for that month. For
example, payments debited on May 5th will pay for the month of May.

Credit/Debit Card # (visa, mastercard, amex, discover): ____________________________________
Expiration Date: ______________________ CVC (3 or 4 Digit): ______________________
Cardholders Name: ______________________________________________________________
Billing Address: _________________________________________________________________
City/State: ___________________________________! Zip: ________________________
Billing Email (to send reciepts): _____________________________________________________
Cardholder Signature: ___________________________________________________________
Please charge my credit card for the monthly tuition on the following day (check which you prefer):
_______! 5th of each month to pay for that month’s tuition
_______ H