Credit Card
Authorization
F
orm
Name
of
S
tuden
t(s):
S
tuden
t(s)
ID
No.:
Persons Name
on the card:
Billing
A
ddr
ess:
I
hereby authorize
E
dmonds
Community College
to charge:
A
moun
t:
USD
Amount in words: dollars
On
my credit
card (check
one)
M
ast
erC
ar
d
American Express
D
isc
o
v
er
C
r
edit
C
ar
d
N
umb
er
:
Expir
a
tion
da
t
e
(MM/Y
Y
)
:
/
S
ecur
it
y
C
o
de
(3
digits
on
the
back
of
the
c
ar
d)
:
For (check all that
applies)
:
Tuition
Other (amount in USD and explanation)
S
igna
tur
e
of
Cardholder
(as shown on your Credit
C
ar
d)
Date