ACH Authorization Form

ACH/CC Authorization Form

I agree to permit WPI Festival On The Land to process payment/s via the selected payment option of ACH Debit (electronic check), or Credit Card, per choice selected in 'Choose Your Payment Plan Method' section of this form. Please note that Credit payments will be assessed a 4% transaction fee. (For example: $70.00 plus 4% equals a total of $72.80)

Contact Information
First Name*
Last Name*
Address*
City, State/Province*
Zip Code*
Email Address*
Enter Email Confirm Email
Phone*
Provide Primary Contact Number
Payment/ Payment Plan Amounts & Dates*
Choose Your Payment Plan Method*
Credit Card
Name on Card*
Credit Card #*
Expiration Date*
MM slash DD slash YYYY
Choose last day of month; i.e. 30 or 31, if 'day' is not shown on card.
Code (usually a 3 or 4 digits on back of card)*
ACH Debit Authorization
Please complete this section.
Account Type*
Account Number*
Routing Number*

Routing Number
Account Holder Name
Consent*
I agree to permit WPI Festival On The Land to Process payment/s via the selected method.
I agree to permit WPI Festival On The Land to process payment/s via the selected payment option of ACH Debit (electronic check), or Credit Card, per choice selected in 'Choose Your Payment Plan Method' section of this form. Please note that Credit payments will be assessed a 4% transaction fee. (For example: $70.00 plus 4% equals a total of $72.80)
CAPTCHA

ACH/CC Authorization Form

Contact Information

Credit Card

ACH Debit Authorization