CREDIT CARD PAYMENT AUTHORIZATION FORM

Please sign and complete this form to authorize Summa Global Education to make a one-time charge to your credit card listed below. By signing this form you give us permission to charge your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated charge or credits to your account.

I authorize Summa Global Education to charge my credit card account indicated below for on or after This payment is for . (Student’s Name : ).

Billing Address

Phone Number

City, State, Zip

Account Type

radioCardType) && $my_application->radioCardType == 'Visa') checked @endif> Visa

radioCardType) && $my_application->radioCardType == 'MasterCard') checked @endif> MasterCard

radioCardType) && $my_application->radioCardType == 'AMEX') checked @endif> AMEX

radioCardType) && $my_application->radioCardType == 'Discover') checked @endif> Discover

Cardholder Name

Account Number

Expiration Date

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)

SIGNATURE

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the services described and indicated amount listed above and valid for one time use only. I certify that I am the authorized user of this credit card and that I will not dispute the payment with the credit card company; so as long as the transaction corresponds with the terms indicated in this form.

WIRE TRANSFER BANK INFORMATION

Bank name: PNC Bank
Account holder: Summa Global Education Inc. DBA AnB Education™
ABA Number: 031000053
Account Number: 8629102721
Swift code: PNCCUS33
Bank Address: 1216 Welsh Rd, North Wales, PA 19454 U.S. Tel: 1-215-412-8800

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