Credit Card Authorization Form - California College of Music

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Credit Card Authorization Form

Information

Name:As it appears on your card

Email:a valid email

Billing Address

Street Address:

City:

State/Region:

Country:pick one!

Credit Card Information

International cards will be charged a 5% convenience fee

Credit Card Number:

Expiration Date (MM/YY):

Security Code:

Amount to Charge (example 100.00):

Total amount you will be charged including the additional 5% convenience fee:

Total: $[field39 * .05 + field39]

Payment Reason

Explain:your full name

Full Name of Student?Applicant Full Name

Relationship to studentRelationship

Agreement

In lieu of your wet ink signature, please type your full legal name below if you agree to the following:

I authorize California College of Music to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.

Signed Signature

Dateof appointment