Credit Card Charge Authorization Form
for Distance Education Students
(print FORM, FILL OUT, Sign, and return by fax or mail)

I, ______________________________, do hereby authorize Craven Community College to charge my:

(Check all that apply)

    ___ Tuition and fees
    ___ Video shipment charges 		____________________________________
Signature

____________________________________
Date

Select Credit Card

_____ MasterCard         _____ Visa
Credit Card Number _______ - _______ - ______ - ______  

Card Verification Number
What is this? The verification number is a 3-digit number printed on the back of your Visa or Mastercard. It appears after and to the right of your card number.

_______

Expiration Date

_______ / _______
       month / year

Name, as it appears on card  (print)

_________________________________________

Student ID Number

______ - ____ - ________

Home Phone Number

______ - _____ - _________

Work Phone Number

______ - _____ - _________

      Please provide us with a person to contact in the event there is a problem with the credit card.  

First & Last Name

_________________________________________

Address

_________________________________________

City, State, Zip

_________________________________________

Email Address (if known)

________________________________________

print and fax this Authorization form to the College Business Office at 252-672-7507 or mail to:

Craven Community College
Attn: Business Office
800 College Court
New Bern, NC  28562