Billing Information

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Bank Account Information

Name on Account

ABA Routing Number

Account Number

Bank Account Type (Only For Bank Account)

Checking
Savings
Business Checking

Bank Name

Credit Card Information

Name on Card

Credit Card Number

Expiration Date

Customer Billing Information

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Phone

I _____________, the parent of _______________ authorize for Day Care to enroll me in automatic payment.

Signature

Note: We will charge the account on every Tuesday

Phone