Credit Card Authorization Form Template - Free Download
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CREDIT CARD AUTHORIZATION FORM
Please fax or mail this form to Family & Graduate Housing at (217) 244-1200 to authorize payment of
charges indicated below. Do not email this form or any credit card information. For questions, please
feel free to contact Family & Graduate Housing at (217) 333-5656 or apartments@illinois.edu.
Name:
(Please print) First Middle Last
Name as it appears on credit card:
(Please print)
Type of credit card: Visa MasterCard Discover American Express
Credit Card No:
Expiration Date: *CV2 Code:
*The CV2 Code is the three digits on the back of the credit card to the far right of the signature.
Please indicate authorized charge below:
Housing Deposit ($250)
Guest Housing
Short Term Lease
Pre-School Application Fee ($50)
Pre-School Tuition
Other
Signature of cardholder:
Date:
T:\FGH\Shared\Administrative_Info\Budget\CREDIT CARD AUTHORIZATION FORM.docx
12/6/13LB
Office Use Only
Processed by:
Date Processed:
source: housing.illinois.edu
