Your name

Your email

_______________________________________________________________________________________________

SCHOOL/LOCATION NAME(S):

CREDIT CARD TYPE: VISAMASTERCARD

CREDIT CARD NUMBER:

CREDIT CARD EXPIRATION MONTH:

CREDIT CARD EXPIRATION YEAR:

CREDIT CARD SECURITY CODE:

NAME ON CARD:

CARD HOLDER EMAIL:

CREDIT CARD BILLING ADDRESS:

CREDIT CARD BILLING CITY, STATE AND ZIP:

ACCOUNT HOLDER PRINT NAME:

DATE:

ACCOUNT HOLDER SIGNATURE:
[signature* signature-372 cols:1200 rows:200 background:#EDEDED]

By signing above, I hereby represent and warrant that he or she has read, understands, and agrees the above Payment
Authorization Form references and is a counterpart of the Agreement previously entered into by School Management and Record
Tracking, Inc. (“SMART”) and the Customer and is duly authorized to sign this Payment Authorization Form on behalf of the
Customer he or she represents. I understand the Agreement required an initial twelve (12) month term commitment which
commenced on the Effective Date as shown in the Agreement and upon completion of each (12) month term the Agreement will
continue and automatically renew on a twelve (12) month recurring term commencing in the ensuing calendar year from the
Effective day, unless Customer provides written notice to [email protected] of intent to terminate the Agreement
and/or its License Subscription at least (30) days in advance of the renewing term; however, I understand and agree on behalf of
the Customer I represent to pay the remainder of the Agreement and its License Subscription until end of current Term, and all
other amounts due and owing before termination is effective, subject in accordance with the Agreement. Effective Date can be
located on the Agreement and for convenience purposes only on the monthly invoices.
By signing above, I hereby authorize SMART to store my card details and automatically deduct funds from the credit card
account I have designated above to bring the account current and to automatically pay the License Subscription total identified on
the Agreement, on the first of every month on an ongoing basis (as such amounts may be adjusted from time to time in
accordance with the Agreement). License Subscription are non-refundable unless otherwise identified in the Agreement.
I understand this form is valid if I remain as a SMART customer. I understand that my withdrawal of permission to deduct funds
from the credit card account I have designated above must be received by SMART, in writing, at [email protected]
a minimum seven (7) days before the first day of the month. I understand that, in the event the withdrawal of my permission, I am
still responsible to pay the License Subscription total identified on the Agreement and have an active credit card on file while
within Term, and that failure to pay will result in the suspension of services and SMART’s current collection methods, if required.
To prevent service interruptions or reactivation fees, please notify SMART, in writing of ANY CHANGE to your account
information. SMART reserves the right to modify or decline or cancel any payment methods at any time. All amounts payable
shall be made in U.S. dollars. Customer shall be responsible for sales tax (if applicable). Commencing five (5) days after the due
date, any unpaid fees shall bear interest at the rate of 1.5% per month, or, if less, the maximum amount allowed by applicable
law, until paid. SMART may also require a User Reactivation fee of Fifty Dollars ($50.00)