Recurring Payment Authorization Recurring Credit Card Payment AuthorizationDate 日期Email 电邮First Name 名字Last Name 姓名Current Phone/Mobile 目前联系电话Will you be the student of Musipire/Online Music Lesson.com yourself (adult or above 18) or Your children will be the students of Musipire/Online Music Lesson.com? 您是本人即将成为伟乐/Online Music Lesson.com的学生 (成人或18岁以上),或者是您的孩子即将成为我们伟乐/Online Music Lesson.com的学生? Myself 本人 My Children 我的孩子How many of your children will be enrolled at Musipire Music School/Online Music Lesson.com? 您有几位孩子会在伟乐/Online Music Lesson.com上课?- Select -12345Child First Name 孩子名字Child Last Name 孩子姓名Child First Name 孩子名字Child Last Name 孩子姓名Child First Name 孩子名字Child Last Name 孩子姓名Child First Name 孩子名字Child Last Name 孩子姓名Child First Name 孩子名字Child Last Name 孩子姓名You authorize regularly scheduled charges to your credit card. A receipt for each payment will be provided to you and the charge will appear on your credit card statement. You agree that no prior-notification will be provided unless the date or amount changes, in this case, you will receive our advance notice before receiving the payment.I authorize Musipire Music School & Academy and Online Music Lesson.com to charge my credit card / debit card on the first day of each month.Types of Credit Card 信用卡类别 VISA MASTER AMERICAN EX DISCOVERCard Holder First Name 信用卡名字Card Holder Last Name 信用卡姓名Card Number 卡号Exp. Date 失效日期CVVBilling Address 信用卡地址Address Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe I understand that this authorization will remain in effect until I cancel it by submitting the withdrawal form before the 20th of my last month. If the payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form. I have been made aware, read over and agree that I must fill out and submit “withdraw form” by the 20th of my last month to have my charges at Musipire Music Academy and Online Music Lesson.com discontinued. ~~~~~~~~~~~~~~~~~~~~~~~您已授权信用卡定期自动付款。我们会为您提供每笔付款的收据,并且付款费用会直接显示在您的信用卡帐单上。您已同意并确认除日期或付款金额有变动外,本中心和公司将不再预先提供定期收款通知。本人已确认并授权Musipire Music School & Academy和Online Music Lesson.com在每个月的第一天向本人信用卡/银行卡自动收费。 本人已确认,除非本人在当月(最后一个月)20日前提交“取消课程自动收费“表格,自动付款授权将一直有效 本人已确认,如付款日期出现在周末或假日时,付款将会在下个工作日自动执行 本人已确认,本人是该信用卡的授权用户,我同意此交易授权书中所提的条款事项,并对这些定期的交易不提出任何异议 本人已确认阅读并同意如有任何变动,本人必须在当月(最后一个月)的20日之前填写并提交 “取消课程自动收费“表格,以终止Musipire Music Academy和Online Music Lesson.com的自动收费。 Signature 签名 Sign Here Submit Form