Authorization - Orange County Lingual Institute

Please Note: This form is meant to provide authorization to charge and keep your credit card on file.

Your Name

Daytime Phone

Email Address

Payment Method:

Card Number:

Expiration Date:

Card Holder Name:

as shown on card

Card Holder ZIP Code:

from credit card billing address

Credit Card Authorization: *

I understand my information will be saved to file for future transactions on my account. You may remove your credit card on file at any time by contacting us. This authorization will remain in effect until then.

I authorize Orange County Lingual Institute to charge my credit card above for agreed upon purchases.

If you are human, leave this field blank.