Possibilities Northeast

Client Name

First Name^*

Last Name^*

Parent / Guardian Name

First Name

Last Name

Email^*

Billing Address

Street

City

State

Zip

Payment Information

Credit Card Number

Expiration Date

CVC

Amount

I hereby authorize the charges outlined above to be applied as designated above pursuant to the signed Proposal or Invoice. I certify that I am an authorized user of this credit card and will not dispute the transaction with my credit card company so long as the transactions correspond to the terms indicated in this authorization form and the Proposal.