CREDIT CARD AUTHORIZATION FORM
Purchase College/State University of New York
735 Anderson Hill Road., Purchase, NY 10577
Phone: 914-251-6510
Fax: 914-251-5959

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.

 

 

_____________________________________  _________________________________________

Student's Name                                                           Student ID Number (Social Security Number)

 

I authorize Long Island University to charge my account in the amount of: $__________________

 

CARD TYPE: CREDIT___DEBIT____         VISA____ MASTERCARD_____ DISCOVER_____

 

____ ____ ____ ____ ____ ____ ____ ____ _____ _____ _____ _____ _____ _____ _____ _____

 

 

______/_______
Expiration Date

 

 

________________________________  _______________________________________________

Cardholder’s Name (Print)                                                        Cardholder’s Signature

 

 

 __(____)________________________  ________________________________________________

Telephone Number

                                                                         _______________________________________________

                                                                                              Credit Card Billing Address

 

                                                                        _______________________________________________

 

 

After completing this form, mail to address above or FAX to (914) 251-5959