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

Bank Name*

Bank Account Type*

Routing Number*

Account Number*

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