Credit Card Authorization Form

First Name

Last Name

Talent's Name

Phone

Billing Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

By completing this form, I am approving the Green Room Acting Studio to set up a Paytrace account for the talent listed on this form and to charge appropriately for the services listed below.

Monthly Classes: I understand that I can cancel the monthly on-going acting classes at any time by notifying the Green Room Acting Studio, in writing, ten (10) days prior to the first of the month.

List of Services

(Select ALL that apply)

Kids Acting Classes $100/month
Teen Acting Classes $150/month
Adult Acting Classes $150/month
Workshop/Seminars
Photo Shoot
Skype Coaching
Self-Taping Services
Connect NYC

Credit Card Number

Credit Card Expiration Date

Security Code

Signature

I am authorizing my credit card to be charged for the items above.

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