Authorization for Credit Card Use

Leap of Language Inc.

37171 Sycamore Street, Apt. 633 Newark, CA 94560

stcin001@gmail.com

205-534-4330

Authorization for Credit Card Use

By signing this form you give Leap of Language Inc. permission to debit your account for the amount indicated on or after the indicated date. This is permission for current and future services as outlined in this agreement, and does not provide authorization for unrelated debits or credits to your account.

First Name

Last Name

Address

Credit Card

Credit Card Expiration Date

3 Digit Card CVV Number

I authorize Jessica Mascarella to charge fees rendered for therapy services to the credit card provided herein.

I understand that the provided credit card will be charged for services rendered (after each session / at the end of the month) and that I will receive a printed invoice as a receipt of payment.

Cardholder Please Sign and Date

Today's Date

Credit Card Authorization

I authorize Leap of Language Ince. to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for therapy services, for the amount invoiced by the practice, and is valid for ongoing monthly and weekly services. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Submit

Leap of Language Inc.

37171 Sycamore Street, Apt. 633 Newark, CA 94560

stcin001@gmail.com

205-534-4330

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Authorization for Credit Card Use

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