Recurring Billing Form


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Please fill out the form below in order if you would like to pay by recurring billing.  If you choose the recurring billing, your account will be automatically deducted the amount of your invoice on the 18th of the month.  If you feel more comfortable mailing us the form rather than filling it out online, please download and fill out the form (click to download form).

Be sure to hit the submit button at the bottom to submit the form!  Thank you so much!


  1. Please provide the following contact information:
Student  Name
Phone Number
Email receipts to
Name on Account
Bank Name
Bank Routing Number
Bank Account Number
Bank Account Type
Checking  Savings Business Checking


I hereby authorize Merry Melody Music Academy to automatically debit my bank account listed above on the 18th of each month for the amount owed to Merry Melody Music Academy, Inc. as detailed in the monthly invoice received by the 5th of the month.

I agree to notify Merry Melody Music Academy in writing of any changes in my account information or termination of this authorization by the 1st of the month.

I understand that cancellations must be made in writing and I will not dispute Merry Melody Music Academy’s recurring billing with my bank so long as the amount corresponds to terms indicated in this contract.

I guarantee and warrant that I am the legal cardholder/duly authorized check signer on the above account(s), and that I am legally authorized to enter into this recurring billing agreement with Merry Melody Music Academy.

By typing my name, I electronically agree to the terms above and this will stand as my electronic signature.


Please type name



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Contact Information

377 Nahatan Street
Norwood, MA 02062
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