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 firstname.lastname@example.org.
(Please print) First Middle Last
Name as it appears on credit card:
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)
Short Term Lease
Pre-School Application Fee ($50)
Signature of cardholder:
T:\FGH\Shared\Administrative_Info\Budget\CREDIT CARD AUTHORIZATION FORM.docx
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