WHEN COMPLETE, SCAN AND SEND TO:
walkerr@gptc.edu or youngd@gptc.edu (DeKalb Campus); lanek@gptc.edu (Newton Campus)
For questions, call 404.297.2432 (DeKalb) / 770.784.3003 (Newton)
CONFERENCE & SPECIAL EVENTS VENUE
CREDIT CARD AUTHORIZATION
DEKALB & NEWTON CONFERENCE CENTERS
Rontai Walker
404.297.9522, EXT 1800
walkerr@gptc.edu
Kevin Lane
770.784.3003
lanek@gptc.edu
Damita Young
youngd@gptc.edu
DEKALB CONFERNCE CENTER
DEKALB CONFERENCE CENTER
NEWTON CONFERENCE CENTER
404.297.9522, EXT 1804
I,
,
$
authorize Georgia Piedmont Technical College to charge my credit/debit card in the amount of
TODAY'S DATE
EVENT DATE
American Express
Discover Master Card Visa
CARD TYPE:
EVENT NAME
NAME ON CARD
CARD NUMBER
EXPIRATION DATE (MM/YY):
PHONE NUMBER
E-MAIL
SIGNATURE
NOTE: When paying by credit/debit card, a signature is required. For your convenience, we accept
payments over the phone. In order to obtain your signature, you may complete and sign this form, or
you may provide your card information via phone and sign and return the scanned receipt.
click to sign
signature
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