Student ID#
Last Name First Name Initial
First Name Last Name
Address
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Email Home Number
Cell Number
Work Number
Choose Credit Card Type:
Credit Card # Expiration Date 3 Digit Security Code*
Amount to be charged** Term Year
Date
Cardholder's Signature
Credit Card Payment by Fax Authorization
Student Finance Office
North Idaho College
Card Holder's Information
Student Information
Credit Card Information
**I authorize North Idaho College to charge the above referenced card for a deposit.
Fax completed and signed form to (208) 769-3431, Attention: Student Finance Office
North Idaho College*Student Finance Office*1000 W. Garden Ave*Coeur d'Alene, ID 83814*studentfinance@nic.edu*Fax 208-769-3431
Visa MasterCard Discover American Express
Choose Authorization Type
**I authorize North Idaho College to charge the above referenced card only for the amount specified to be used as payment
for tuition, fees and/or residence hall changes owed.
I authorize North Idaho College to charge the above referenced card for the outstanding balance owed for tuition, fees
and/or residence hall charges owed.
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