cashier’s office debit/credit card authorization … · 2017-11-27 · debit/credit card...
TRANSCRIPT
CASHIER’S OFFICE DEBIT/CREDIT CARD AUTHORIZATION FORM
GEORGIA PIEDMONT TECHNICAL COLLEGE495 North Indian Creek Drive Clarkston, GA 30021-2397
(404) 297-9522, ext. 1249
authorize Georgia Piedmont
Technical College to charge my debit/credit card in the amount of $
NAME ON DEBIT/CREDIT CARD:
BILLING ADDRESS OF CARDHOLDER:
TYPE OF DEBIT/CREDIT CARD:American Express Is not accepted.
DEBIT/CREDIT CARD NUMBER:
3 digit code located on the back of the card on the signature strip
EXPIRATION DATE: (mm/yy)
CARDHOLDER SIGNATURE: _____________________________________________
DAYTIME TELEPHONE NUMBER:
STUDENT NAME:
UPON COMPLETION OF THIS FORM PLEASE FAX IT TO 404-298-5235. AUTHORIZATION RECEIVED AFTER 3:00 PM MAY BE PROCESSED THE NEXT BUSINESS DAY.
I,
VISA MASTERCARD DISCOVER
DATE:
STUDENT ID NUMBER:
SECURITY CODE: