White-Facilities Yellow-Requestor Pink- CCFL (Retain) Application for Permittee District Facility Use
Civic Center Facilities & Leasing
900 Otay Lakes Road
Chula Vista, CA 91910
One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize Southwestern Community College District-Civic Center
Facilities & Leasing Department to make a one-time debit to your credit card listed below to be applied to
the SWC Civic Center Facilities & Leasing Agreement/Invoice for event reservation & related services.
By signing this form you give us permission to debit your account for the amount indicated on or after the
indicated date. This is permission for a single transaction only, and does not provide authorization for any
additional unrelated debits or credits to your account.
Please complete the information below:
I ____________________________, a representative of ____________________________ authorize
(Full Name) (Organization Name)
SWC Civic Center Facilities & Leasing to charge my credit card account indicated below for _____________ on or
after ___________________. This payment is for _____________________________________.
(Date) (Description of goods/services)
Billing Address ____________________________ Phone# ________________________
City, State, Zip ____________________________ Email ________________________
Account Type: Visa MasterCard AMEX Discover
Cardholder Name _________________________________________________
Account Number _____________________________________________
Expiration Date ____________
CVV2 (3 digit number on back of Visa/MasterCard, 4 digits on front of AMEX) ______
AUTHORIZED SIGNATURE DATE
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment
authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an
authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms
indicated in this form.
*Please print, scan & email this form to: firstname.lastname@example.org
*Please print & mail this form to the address above: ATTENTION: Civic Center Facilities Leasing-Office 1633
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