NPC SECURE CDS Patrons: As of Aug.

25th 2011 Colettes Dancing School will be requiring a Checking account auto debit (below) for payments. Debit/Credit cards will be used only as a secondary (back-up) form of payment. BOTH are required if your total monthly tuition exceeds $100. If you cannot produce a checking account for auto-pay tuition will be 15% more and the cash/credit account must be kept current or lessons will be immediately terminated. AUTHORIZATION FOR DIRECT PAYMENT
I authorize Colettes Dancing School and my financial institution named below to initiate entries to my checking or savings account and/or credit card to pay Colettes Dancing School. This authority will remain in effect until May 31st 2012. Or if I notify CDS in writing to cancel it in such time as to afford my financial institution and Taylor Electric Cooperative a reasonable opportunity to act on it.

Checking and Savings Information

_______________________________________________________________________ (Name of Financial Institution) (Branch) _______________________________________________________________________ (City) (State) (Zip Code) Account #___________________________________Checking______or Savings______ Financial Institution Routing Number _________________________________________ Tuition will be debited on the 7th of every month. Teams Only: I would like my Payment Plan to be debited on the 25th of each month _____ Special Instructions(enter if youd like costume/performance fees charged as due):________________________ Signature:_____________________________________________Date_____________ Please include a voided check for checking account ACH

month. If checking funds are unavailable this card will be charged plus a $10 fee.) _____Mastercard _____Discover _____Visa _____Amex Credit Card #_______________________________________ Exp. Date____________

Debit/Credit Card Information (Secondary-Required if CDS tuition is $100 or more per

I will be responsible for notifying Colettes Dancing School of any account number or expiration date changes. If I Do Not I understand fees will be charged. Signature:_________________________________________Date__________________