Ears of Experience One-Time Payment Authorization Form

Please complete this form to authorize Ears of Experience to make a one-time debit to your credit card listed below.

By placing a tick in the Confirmation box below and submitting this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete all the fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.

Client Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Payment Information

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Name on Card *

CVV Code *

Amount to be Charged *

Date of Payment * +

Description of Goods and Services *

Signature *

clear

Confirmation *

I authorize Shannon Stuemke an agent with Ears of Experience to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. 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 this form.

Card on File Authorization *

I understand that my credit card information will be saved on file for possible future transactions on my account.

This card may also be used for additional payments for items marked below, but only when written instruction to use the "card on file" for payment is given.

Ears Tip!

Please add your credit card information to your “My Disney Experience” account profile for Advance Dining Reservation bookings. The costs for these reservations will vary and you will be notified of the price before making any such reservation. These reservations can be seen in your My Disney Experience account after they are booked. Make sure to check your reservations in your account and make any changes or cancellations at least 24 hours in advance (for most dining reservations) to avoid unnecessary credit card charges. Keep in mind that dessert parties have a 5-day cancellation policy while dinner shows, and Cinderella’s Royal Table have a 48-hour cancellation policy.

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