Kenosha Symphony Orchestra Scheduled Credit/Debit Card Payment Form Please print this form, complete, and mail to: Kenosha Symphony Association 6501 Third Avenue Kenosha, Wisconsin 53143

Scheduled Credit/Debit Card Payment Form

Name:___________________________________________________________

Telephone:_______________________________________________________

Email Address:____________________________________________________


I authorize a charge against my credit/debit card on the 1st of each month,

in the following amount: $______________

Starting Date:_____________________ (MM/DD/YY)

Card: (choose one) ___MasterCard    ___Visa

Account No.______________________________________________________

Expiration Date:___________________________________________________

Billing Address:___________________________________________________

City/State/Zip:____________________________________________________

Signature________________________________________________________

Today's Date:_____________________________________________________

Note: Scheduled charges will remain in effect until revoked in writing to the Kenosha Symphony Orchestra Office.

Your contribution is tax deductible to the extent allowed by law. Please consult with your tax advisor for further infomation.