Second Language, LLC
Payment by Credit Card

You may pay for language lessons using your credit card.
We accept Visa, Master Card, Amex, Discover.
Bring your credit card to our office when you enroll for language lessons.

You may also print this page, fill it in and bring it to us or mail it. (Additional forms in office).

If you prefer, you may phone us with your credit card information. (860) 202-9011
If you prefer, you may pay us by check, payable to Second Language, LLC.

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Amount to be charged: $_______

First name as it appears on card: ______________

Last name as it appears on card: ______________

Card Type: ______________ (Visa, Master Card, Amex, Discover)

Card Number: ____________________________

Expiration date: Month: _______ Year: _______

Card Security Code: _______ (3 or 4 digit number on back of card)

Address line 1: ____________________________

Address line 2: ____________________________

City: ___________________________________

State: _______

Zip code: ______________

Email (optional): ____________________________

Telephone: ____________________________

Signature: ____________________________

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Charges will appear on your credit card statement as "Second Lang"

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This authorizes Second Language, LLC to charge the amount indicated above for language lessons one time only. This information will be destroyed once the charge is authorized.