Make a Payment | NYLA Talent

The payment is for (enter Talent Name and the program name):

Artist Name

Card Holder Name

Address

City

State

Zip Code

Phone

Card Type

Credit Card Number

Expiration Date (MM/YY)

Security Code

First Amount

First Date

First Auth Code

Second Amount

Second Date

Second Auth Code

Third Amount

Third Date

Third Auth Code

Card Holder Signature

I Hereby Authorize NYLA Talent to charge my credit card for the amount(s) listed above on the date(s) listed above. I understand there is a $25.00 fee per attempt for cards that are not approved on these dates.

Date

License Number/State

Legal Name

Birthdate