Automatic Payment Consent

I hereby authorize Portland School of Music & Dance, Inc. to charge my account in the amount of $308 on the 22nd day of November, December, and January; and $231 on the 22nd day of each month following, beginning February 22nd, 2017. I will give a 30-day written notice to discontinue these charges. I understand that all automatic payments will stop after the 30-day period.

Name *