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St. Stanislaus Tri-Parish School
641 5th Avenue
Lewiston, ID 83501
(208) 743-4411
Fax (208) 743-9563
Credit Card Charge
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_________________________
Expiration Date_______________________
Amount per Month $_____________________
*Start Date______________________
*End Date______________________
Signature______________________________ Date______________________
*All Credit Card Charges will be processed on the 15th of each
month.
Please return completed form to SSTPS, Attention: Bookkeeper
St. Stanislaus Tri-Parish School
641 5th Avenue
Lewiston, ID 83501
(208) 743-4411
Fax (208) 743-9563
Electronic Funds Transfer
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 15th
OF EACH MONTH
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