Get documents about "Credit Card Payment Form
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- posted:
- 5/31/2012
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- English
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Document Sample
Credit Card Payment Form
Financial Services, Athabasca University You may use your VISA®, Mastercard®, or American Express® card to pay Athabasca
1 University Drive, Athabasca, AB T9S 3A3 University fees.
Toll Free in Canada/US: 1.800.788.9041
Other: 780.675.6111, Fax: 780.675.6174
Payment Name: _____________________________________________
STUDENT ID NUMBER (if applicable)
(please print) Address: _____________________________________________
_____________________________________________________________________
POSTAL/ZIP CODE
r VISA® r MasterCard® _________________________________________
r AMERICAN EXPRESS® _____________________________________ _________ / _________
EXPIRY DATE
DESCRIPTION AMOUNT CHARGED
(e.g., application fee or course name and number )
The personal information collected on this form will be used for the purpose of pro- Where incorrect fees are
cessing payments. This personal information is being collected under the authority listed, Athabasca University
of Section 33(c) of Alberta’s Freedom of Information and Protection of Privacy Act. If
you have any questions about the collection and use of this information, contact
will automatically
the Senior Accountant, Athabasca University, 1 University Drive, Athabasca, Alberta, charge your account with
T9S 3A3, Phone: 800.788.9041. the correct amount.
TOTAL
Signature: ____________________________________________ Date: __________________
Payment Name: _____________________________________________
STUDENT ID NUMBER (if applicable)
(please print) Address: _____________________________________________
_____________________________________________________________________
POSTAL/ZIP CODE
r VISA® r MasterCard® _________________________________________
r AMERICAN EXPRESS® _____________________________________ _________ / _________
EXPIRY DATE
DESCRIPTION AMOUNT CHARGED
(e.g., application fee or course name and number )
The personal information collected on this form will be used for the purpose of pro- Where incorrect fees are
cessing payments. This personal information is being collected under the authority listed, Athabasca University
of Section 33(c) of Alberta’s Freedom of Information and Protection of Privacy Act. If
you have any questions about the collection and use of this information, contact
will automatically
the Senior Accountant, Athabasca University, 1 University Drive, Athabasca, Alberta, charge your account with
T9S 3A3, Phone: 800.788.9041. the correct amount.
TOTAL
Signature: ____________________________________________ Date: __________________
Payment Name: _____________________________________________
STUDENT ID NUMBER (if applicable)
(please print) Address: _____________________________________________
_____________________________________________________________________
POSTAL/ZIP CODE
r VISA® r MasterCard® _________________________________________
r AMERICAN EXPRESS® _____________________________________ _________ / _________
EXPIRY DATE
DESCRIPTION AMOUNT CHARGED
(e.g., application fee or course name and number )
The personal information collected on this form will be used for the purpose of pro- Where incorrect fees are
cessing payments. This personal information is being collected under the authority listed, Athabasca University
of Section 33(c) of Alberta’s Freedom of Information and Protection of Privacy Act. If
you have any questions about the collection and use of this information, contact
will automatically
the Senior Accountant, Athabasca University, 1 University Drive, Athabasca, Alberta, charge your account with
T9S 3A3, Phone: 800.788.9041. the correct amount.
TOTAL
Signature: ____________________________________________ Date: __________________
June 09
