I, _____________________________________________________, hereby

                               (FULL NAME)

authorize Ron Jon Surf School to charge my credit card:

(    )    Visa

(    )    Mastercard

account # __xxxx xxxx xxxx_______________________________

                       (CARD'S LAST 4 DIGITS ONLY - PLEASE CALL TO INFORM FULL NUMBER)

Expiration: ________ /________ in the amount of US$ _______________

                          ( MM     /      YY )                                                       (AMOUNT)

_______________________________________________________ Dollars

                               (WRITTEN AMOUNT)

For payment of surf instruction arrangements for myself and / or:

_____________________________________________________________

Corresponding to:

(Please check)                   (     ) - 25% security deposit for surf lesson.

                        (     ) - 50% deposit for Kids Summer Camp or Jr. Team.

                        (     ) - other ____________________________________

                                                       ( PLEASE SPECIFY)

Billing address _________________________________________________

City ______________________________ State _________ Zip __________

Contact: Home ( ____ ) _______________ Office ( ____ ) ______________

           Cell ( ____ ) __________________ Fax ( ____ ) _______________

           Email _________________________________________________

________________________________________________   ____________

                       (SIGNATURE OF CARDHOLDER)                                           (DATE)

                        PLEASE e-mail: ccsurfs@aol.com or FAX to (321) 868-1983