Dassel-Cokato Community Education l 4852 Reardon Ave SW, Suite 1400 l Cokato, MN 55321 l 320-286-4120 I hereby authorize Community Education to debit my credit card/bank check card for my Charger Kids Club payment each month. I understand that my account will be debited at the beginning of each month (September-May). I have the right to cancel this agreement at anytime, but also understand that payment must be made by check, money order or cash by the 1st of each month if I decide to cancel this authorization form. A receipt will be available upon request each month showing that the credit card/bank check card transaction has taken place. Please complete the following:
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INITIALS: ______. TYPE OF CARD: VISA. MASTERCARD. AMERICAN EXPRESS. CREDIT CARD NUMBER: XXXX - XXXX - XXXX - ______(Please fill out the last 4-Digits Only). (Attach the Credit Card Information Slip Sheet). EXPIRATION DATE (Mo/Yr): ______/___
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There was a problem previewing this document. Retrying... Download ... or edit this item. ICL_Authorization-Form-ACH-Credit-Card-Recurring-Payment.pdf.