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Home
About
What We Do
Facilities
Contact
Forms
CC Authorization Form
Intake Packet
Take Action
Forms
CC Authorization Form
Intake Packet
Stay the Course
Credit Card Authorization Form
Company Name
Name on Card
*
First Name
Last Name
Card Holder Billing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Rent Payment (Stay the Course)
*
Deposit (Stay the Course)
*
Total Charge Amount
*
Card Type
*
Visa
MasterCard
American Express
Discover
Card Number
*
Card Expiration Date
*
Card Identification Number
*
Please read thoroughly
*
I authorize the credit card listed above to be charged the total charge amount in this authorization form according to the terms outlined in your Stay the Course (STC) agreement. 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 my STC agreement and on this authorization form. Rent shall be run as early as the 27th of the month for the following month. Contact STC if you have any questions about your STC agreement and/or STC refund/cancellation policy. By signing this contract as the responsible party for treatment fees I understand that all fees paid are non-refundable regardless of length of stay. All fees are non-negotiable and due upon the specified date. No verbal agreement will supersede this contract. Stay the Course reserves the right to discharge any resident for violation of House Rules with no refunds given. I hereby agree to hold Stay the Course Sober Living harmless for any and all future claims resulting from this contract. PAYMENTS AND DEPOSITS ARE NON-REFUNDABLE & NON-TRANSFERABLE. Stay the Course requires a 30 day notice before vacating.
I authorize regularly scheduled charges to the credit card listed above. I will be charged every month for the total amount due for that period. I agree that no prior notification will be provided to me for each scheduled payment.
Name
*
First Name
Last Name
Electronic Signature
*
Thank you!