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Any
questions please call the DABH at 248-335-2585
Please Fill out this
form completely and then click "Submit Form" button at
bottom of this page.
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| Student's
First
Name
Student's Last Name |
| Credit
Card Billing Address
City
Zip Code |
| Exact
Name on Credit Card as it appears |
Payment information below |
|
Account
Number
|
Please
update my account to AUTOPAY
<< Check this box for AutoPay with my credit card - MONTHLY
<< Check
this box for AutoPay with my credit card - SESSION
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Optional below unless we don't have this information in the system at
the studio |
| Home
Phone
eMail
Address |
| Mother's
Name
Work Number
Cell Phone |
| Father's
Name
Work Number
Cell Phone |
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