Authorization Form

Name_____________________________________________________________

Address___________________________________________________________

City______________________________State________________Zip_________

I authorize St. Stanislaus Tri-Parish School (SSTPS) to charge my

Credit card monthly as per the instructions listed below:

Visa, Mastercard or Discover Accepted

Name as it appears on the Card

___________________________________________________________________

Visa or Mastercard Number_________________________

Amount per Month $_____________________

*Start Date______________________

*End Date______________________

Signature______________________________ Date______________________

*All Credit Card Charges will be processed on the 15^th of each month.

Please return completed form to SSTPS, Attention: Bookkeeper

Authorization/Request Form

Name:__________________________________________________________________

Please Print

Address:________________________________________________________________

City:______________________________________State____________Zip__________

Telephone:_________________________________

Automatic Bank Withdrawal:

Bank Name_____________________________________________________________

Please Print

Account #______________________________________________________________

Routing #______________________________________________________________

Amount per Month: $____________________________

Start Date:____________________________thru______________________________

Signature:______________________________________________________________

****PLEASE ATTACH A VOIDED CHECK TO THIS SHEET

***ALL ELECTRONIC WITHDRAWALS WILL BE PROCESSED ON THE 15^th

OF EACH MONTH