Resident Student Parking Registration Credit Card Payment

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					                       Resident Student Parking Registration
                               Credit Card Payment
Mail form to:                                                               Fax form to:

CSU Parking Services                                                        CSU Parking Services
2300 Chester Avenue Room 128                              or                at 216 687-5505
Cleveland OH 44115
                                         Please complete entire form.

Student Name                                                        CSU Student ID number (7 digits)


Street Address                                   City                     State           Zip


Home Phone                                       Work Phone




Credit Card Number: ____________________________________________________________

Print name as shown on card: _____________________________________________________

Credit Card Expiration date: __________________

Amount to charge:            $160 for Fall Semester            $320 for full 2010-2011 academic term

     Visa              Mastercard                Discover

I hereby agree to pay the sum set forth above to the bank which issued my card in accordance with the
terms of the credit card for the purchase of goods and services. I also understand if a refund is due it
will be issued in the form of a check made payable directly to the student.

Cardholder Signature :___________________________________________ Date: _____________


Office Use Only
Authorization Number            Date Processed