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Adult Clinic & Lesson Payment
admin
2022-10-13T19:50:58-04:00
Adult Clinic & Lesson Payment
Adult Clinics
On-line PAYMENT for the Pass Academy Adult Clinics or Lessons at the Bullis School
Use this form if you were requested by the Pass Academy Staff to make a payment.
Adult Clinic & Lesson Payment Form
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Email Address
*
Enter Email
Confirm Email
Phone
*
Private Lesson
Private Lesson Dollar Amount
Quantity
Price:
$1.00
Quantity
Enter DOLLAR AMOUNT as instructed by Pass Academy staff.
Lesson Pro's Name
SELECT NAME
Andrew Williams
Bob Taraschi
German Ruiz
JB Barton
Jinny Yu
Jonathan Ai
Lee White
Malcolm Greene
Marija Elenova
Michael Morris
Mike Gee
Nima Golshan
Raul Iriarte
Robert Millwater
Sean Ngo
Zack Shane
OTHER
Other Lesson Pro's Name
Gratuity
Gratuity Dollar Amount
Quantity
Price:
$1.00
Quantity
Enter optional dollar amount for a pro.
Gratuity Pro's Name
SELECT NAME
Andrew Williams
Bob Taraschi
German Ruiz
JB Barton
Jinny Yu
Jonathan Ai
Lee White
Malcolm Greene
Marija Elenova
Michael Morris
Mike Gee
Nima Golshan
Raul Iriarte
Robert Millwater
Sean Ngo
Zack Shane
OTHER
Other Gratuity Pro's Name
Custom Payment Amount
Custom Dollar Amount
Quantity
Price:
$1.00
Quantity
Enter dollar amount as instructed by Pass Academy staff for a custom purchase.
Total Fees
$0.00
Credit Card
*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
Expiration Date
Security Code
Cardholder Name
Additional Information (optional)
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