TutaPoint Credit Card/ACH Authorization Form

Student's Name*
TutaPoint Inc
Beginning
Date
TutaPoint Inc will provide tutoring services to
Services to
TUTAPOINT INC
TUTAPOINT INC CREDIT CARD/ACH AUTHORIZATION FORM
Please fill out and return this form to activate ACH or credit card billing for charges due on your TutaPoint Inc account.
Preferred Payment Type*
- ACH/E-Check
- Credit Card
ACH/E-Check
Bank Name*
Bank Account Type*
- Consumer Checking
- Consumer Savings
- Business Checking
- Business Savings
- N/A
Routing Number*
Account Number*
Credit Card
Card Number*
Security Code*
Expiration Date (Month & Year)*
Card Holders Name*
exactly as it appears on account/card
Billing Address*
City
State
Zip*
Card Holder Phone Number*
Email Address to Send Receipts*
Card Holder Verification*
Type your full name in ALL CAPS in the field above
Date of Signature*
MM
DD
YYYY

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TutaPoint Inc