Summer Payment Plan - Jacksonville Ice and Sportsplex

Payment Plan Contract
Adult Hockey League
I,
, hereby authorize Jacksonville Ice & Sportsplex to charge the credit
card listed on the Credit Card Authorization Form in my name for the amount and dates as outlined below.
I understand that in the event of any charges being declined, the enrollment will be suspended until
payment is cleared.
Player’s name (if different than card holder)
Division
Team Name — If unknown, write “unassigned”
 A
Early Bird (until 5/15/15)
 B
Three (3) equal payments of $70.00
 C
Three (3) equal payments of $90.00
Regular Fee (5/16/15—6/1/15)
Late Fee (after 6/1/15)
 35 + A
Three (3) equal payments of $105.00
 35+ C
 Bevi
· 25% off for each additional Division registered.
· 50% off for each additional goalie registration.
· Payments will be processed 5/15/2015 (or at registration), 6/15/2015 & 7/15/2015. · All payment are PLUS 7% sales tax.
___________________________
___________________________
_________________
Signature
Printed Name
Date
*Paperwork includes: Credit Card Authorization Form, Payment Plan Contract, and proof of current USA Hockey Membership.
 I have a credit card on file. Please use it.
 Please us the Credit Card Authorization attached.
FOR OFFICE USE ONLY:
AMP form on file
Team(s) assigned
Payment plan setup
Input by: ___________________ Date of input: ______________
Received by: ___________________
Date received: ______________
Credit Card Authorization Form
This authorization is made by the below named and signed Account Holder (“you”, “your”
herein) to pay obligations of __________________________________________
(“customer”) to Skate World, d/b/a Jacksonville Ice & Sportsplex (“JIS”).
 This is a new card. Note: new card will replace any existing card.
Credit Card Type (check one): Master Card
Visa
AmEx
Discover
Account Number: ________________________________________________________
Account Holder: ______________________ Exp. Date: ___________ CCV/CCID: _______
Billing Address: ______________________________________________________________
_____________________________________________________________
Contact Phone: ______-______-_________ Email: __________________________________
This form authorizes recurring payments as outlined by the Payment Plan Contract(s) you
authorize, and when verbal approval is given by the card holder.
You authorize JIS to charge the above Credit Card to pay (a) recurring payments as outlined by the Payment Plan
Contract (“PPC”) you authorize and (b) when verbal approval is given by the card holder
The recurring charges will be made monthly on or about the processing dates as outlined by the PPCs you have authorized.
If you wish to stop an upcoming payment, you must notify JIS one week prior to the scheduled processing date as
indicated on the PPC.
By signing, you also understand that once payment has begun processing, it cannot be cancelled or edited.
Refunds are at the discretion of JIS management and policies.
The completing of this release helps us protect you, our valued customer, from credit card fraud. All information
provided is strictly confidential.
Signature of Account Holder:
Date: ______________
FOR OFFICE USE ONLY:
Received by: _________________ Date received: _________ Input by: ___________________ Date of input: ______________