CREDIT CARD AUTHORIZATION FORM

Payment Information

Date
Amount to be charged
Full Amount:
Balance:
Campers name:
Phone
Credit Card:
Card Number
Expiration Date (mm/yy)
Name on Card
CVV (3 digits from the back of the card)

I Confirm that the payment details above are correct and I authorize Camp Ak-O-Mak to use the above credit card for the tuition & any reconciliation of my account.

Business Office: 14-441 Stonehenge Drive, Ancaster, Ontario, Canada L9K 0B1,
Tel.: 416.427.3171, Fax: 905.304.2982
Email: Dianne@campakomak.com Website: www.campakomak.com

Summer Address: 240 Akomak Road, Ahmic Harbour, Ontario, Canada P0A 1A0,
Tel.: 705.387.3810, Fax: 705.387.0077