Recurring Payment Form

Credit Card Recurring Payment Authorization Form

Schedule your payments to be automatically charged to your Credit Card. Just complete and Enter your Initials in the below form to get started!

Recurring Payments Will Make Your Life Easier:

It’s convenient (saving you time and postage)

Your payment is always on time (even if you’re out of town), eliminating late charges

Take advantage of the low monthly payments with no long term contracts

For questions or queries, Contact Bollywood Shake at info@bollywoodshake.com or call 512-257-7425.

Student Name *

Cardholder Name *

Billing Address

Billing City *

Billing State *

Billing Zipcode *

Card Type *

Account Number (Last 4 digits) *

Expiration Date *

Monthly Tuition $ *

Billing Start Date (MM/DD/YYYY) *

E-mail Address: *

Contact Phone Number *

Comments

I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE BELOW STATEMENTS. (Please refer to the CREDIT CARD AUTHORIZATION below) ENTER YOUR INITIALS *

* Required

CREDIT CARD AUTHORIZATION:

I hereby authorize Bollywood Shake to charge this credit card on a monthly basis for the tuition amount indicated above; as such amount due under such contract may change from time to time. If the monthly amount initially charged under such contract changes, Bollywood Shake will provide written notification of the new amount prior to the first scheduled transaction date for that new amount. My credit card will be charged on or about the 1st of each month for the amount due. If necessary, Bollywood Shake may initiate credit adjustments for any charges made in error.
I understand that this authorization will remain in effect until Bollywood Shake or I cancel it in writing. I agree to notify Bollywood Shake in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. No partial month credits will be provided. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.