AZ2Camps-Parties-Programs for Kids! Modeling TM

MODELING A Z, LLC * P.O. Box 150 * Adamstown, MD 21710 * Tel. (301) 801-4556 * Fax (301) 874-8657

www.modelinga2z.com

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Payment Authorization form Name of Student:_________________________________

Name of Class/Party or Program:__________________________________

Type of Credit Card:_______________________________ Visa, MasterCard, Discover, AM EX, Debit

Name of Credit Card Holder:______________________________

Primary Phone Number:____________________________Email:_____________________________________________________

Address of Card Holder:_______________________________________________________________________________________

Credit Card Number:________________________________________

Expiration Date:_____________

Three or Four Digit Code:_________

I authorize Modeling A2Z make an initial charge to my credit card for the following amount $______________

I authorize Modeling A2Z make a balance charge to my credit card for the following amount $___________ on __________ Date

Signature of Card Holder:________________________________________Date:______________

Email to: registration@modelinga2z.com or Fax to: 1-301-874-8657