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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


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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