Online Credit Card Authorization Form

La Bacadilla Language School #43 Churchhill Street, Benque Viejo Del Carmen Belize www.belizespanishschools.com

One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize La Bacadilla Language School to make a one time debit to your credit card listed below. By signing this form you give us permission to debit 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 debits or credits to your account.
Please complete the information below:
Name First Last
Email
Country
Address
City
State/Province:
Postal Code
Phone
Billing Information
Name on Card
Card Number
Card Security Code(3 digits):
Expires On / MM YYYY
Card Type Visa MasterCard
Select Packages

Package	Cost Per Person/Session(USD)	SubTotal(USD)
A1 or A2	$	$
A1.1	$	$
Benque Viejo Heritage Tour	$	$
Visit to “El Castillo” at Xuanantunich	$	$
Visit to Poustinia Land Art Park	$	$
Experience of local cuisine	$	$
The Franciscan trail	$	$
Conversation with a Tipú Mayan Shamán	$	$
Salsa classes	$	$
Slate-carving experience	$	$
Total		$

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 goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Authorization I agree I don't agree