For your convenience we have established an automatic payment procedure. You simply provide us with your credit card information and written permission on the form below, and we will automatically charge your account when it is due. If you have any questions, please call or email Sandi Elfast at (423) 586-3280 or selfast.ases@charter.net.

To Whom It May Concern:

I give All Saints’ Episcopal School permission to deduct the fees indicated below from my credit card account beginning on the ________ day of ____________________________________, ___________.

Parent Name(s): _____________________________________________________________

Student Name(s): ____________________________________________________________

Tuition $____________  Monthly  Annually  One-Time Charge

After Care $____________  Monthly  One-Time Charge

Homework Helpers $____________  Monthly  One-Time Charge

Summer Camp $____________  Two Payments (6/1 & 7/1)  One-Time Charge

Other $____________  Monthly  One-Time Charge

Credit Card Information:

 Visa  MasterCard  Discover

Account Number: _____________________Expiration Date: _________ Security #*: _______ (Month/Year)

Signature: _____________________________________ Date: ______________________

Name As It Appears on Card: ________________________________________________________

Billing Address for Card _________________________________________________

Street Address or P.O. Box

_________________________________________________

State and Zip Code

*The Security Number is the three digit number found on the back of your card.

A service charge of 2% will be added to each transaction.

__________________________________________________________

3275 Maple Valley Road * Morristown, TN 37813 * (423) 586-3280 * Fax (423) 586-9355