Payment Authorization - Levine Jewish Community Center, Charlotte, NC

This form authorizes the Sandra and Leon Levine Jewish Community Center to charge my credit card on file for any services for which a voucher is required for any person included on my account.

First Name

Last Name

Phone (use format nnn-nnn-nnnn or nnn nnn nnnn)

Please select all services/lesson types that apply:

I understand and acknowledge that certain services and lessons provided by the Sandra and Leon Levine Jewish Community Center (LJCC) are paid for by the purchase of a single-session voucher or a package of vouchers. The single-session rate is more expensive than the rate for each session that is part of a package of vouchers.

I, or my family member(s), currently participate in or intend to participate in the services/lessons at the LJCC as listed above.

I hereby agree to put a credit card on file with the LJCC. I further agree that should that credit card be canceled or expire, I will immediately provide a new credit card number or new expiration date to the LJCC. I agree to contact the LJCC Customer Service Center prior to my first or ongoing training session or lesson to provide a credit card.

I hereby agree that should I not have any vouchers purchased and on file at the time of a session/lesson, the LJCC will do as instructed below:

Charge my credit card on file at the prevailing single-session rate. Charge my credit card on file for a new package of vouchers at the prevailing rate which package shall be the same as the previous package purchased.

If I have more than one credit card on file with the LJCC, please use the card that ends in these four digits for the lesson types listed above.

I further agree that the provisions continued herein will remain in effect until such time as I provide written notice to the LJCC by sending an email message to Kristi Fallowes, Controller, at [email protected].