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Coventry University Debit/credit card authorisation form This form can be used to authorise credit and debit card payments, for applicants or students studying at Coventry University. Please complete in block capitals. Payment can only be accepted using the following cards: Eurocard, Mastercard, Visa, Switch, Maestro, Electron, Solo and Delta. This transaction will be actioned immediately. Total amount of payment £ Please complete appropriate section to indicate what the payment is for. Section 1 - Prepayment/accommodation deposit. Please return with accommodation application form and send to Accommodation Office at address no. 1 below. £ Reference number/UID (can be obtained from accommodation form) Section 2 – For all other payments please return to Finance Department at address no. 2 below. Accommodation fees * Tuition fees * Welcome week* Presessional English * Wheel Clamping* £ £ £ £ £40.00 *Once completed please send your form to Finance at address no 2 below. Please note that if you have already faxed this form please do not send the original or you may be charged twice. Please complete the following details in block capitals: Cardholder’s details Name as on card Address Telephone number I authorise you to debit my (select appropriate box) Eurocard Mastercard Visa Switch Electron Solo Delta Card number Amount £ . Valid from / Expiry date / Issue no Security code (Last 3 digits on signature strip) Cardholder’s signature Do you require a receipt Yes No (Please note this will be sent to the address as given above) Please complete the following details in block capitals: Student details Name of student Sex M F University address Date of birth / Email address Postal addresses 1 Accommodation application pre-payments or deposits please return to Accommodation Department. If you have any queries please contact the Accommodation office on: Telephone no: +00 44 24 7688 7303 or 7304 Coventry University, Alma Building Fax no: +00 44 24 7688 7361 Alma Street, Coventry. CV1 5QA. 2 Accommodation, tuition fees and wheel clamping payments please return to Finance. If you have any queries please contact the Finance office on: Telephone no: +00 44 24 7615 2266 Coventry University, Student Centre Fax no: +00 44 24 7615 2276 Gulson Road, Coventry, CV1 2JH.
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