1-SGGA Payment Form

ST. GREGORY THE GREAT ACADEMY
PAYMENT SUBMISSION FORM

This form enables you to submit payments to St. Gregory the Great Academy.
Please complete the information below and submit this form.

Name of Payor*

First Name

Last Name

Purpose*

Grade that this trip is for?*

Save card info as my new lunch payment method

YES NO

Oldest Student's Name*

First Name

Last Name

Phone Number*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Please state the reason for this payment.*

Amount to be charged* $

Select Card Type (A)*

Select Card Type (OC)*

PLEASE NOTE: This is a PAYMENT AUTHORIZATION form. When information is submitted, it may be up to 2 WEEKS until the transaction appears on your statement. This form CANNOT be used for proof of a successful credit card transaction.

CardholderName*

Credit Card Number*

Confirm *

Credit Card Number*

Confirm *

Exp Date*

CVN Number*

Confirm *

Billing Address Street Number*

Zip Code*

Email*

PLEASE NOTE: This is a PAYMENT AUTHORIZATION form. When information is submitted, it may be up to 2 WEEKS until the transaction appears on your statement. This form CANNOT be used for proof of a successful credit card transaction.

Signature*

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Use your mouse or finger to draw your signature above