<< Bursar's Office
Bursar's Office, Kumble Hall
C.W. Post Campus, Long Island University
720 Northern Blvd., Brookville, New York 11548 |
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Credit
Card Authorization Form
Print, fill out and mail/fax to above address/fax number
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| Payments may be made by Visa, MasterCard
or Discover Card. If you are using a debit card, the charge you are
authorizing cannot exceed your daily withdrawal limit set by your
bank. |
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Student Name:
(Last, First, MI) |
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| Student ID Number: |
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| I authorize Long Island University to
charge my account in the amount of: |
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| Credit Card Type: |
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| Credit Card Number: |
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| Credit Card Expiration Date: |
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(mm/yy) |
CVV2 Security Code (3 Digits) |
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| Cardholder Name: |
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| Phone Number: |
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| Mailing Address: |
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| Cardholder Signature: |
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