T: +1 671.735.2940/2945 F: +1 671.734.2907 W: www.uog.edu
Mailing Address: 303 University Drive UOG Station Mangilao, Guam 96923
The University of Guam is a U.S. Land Grant Institution accredited by the Western Association of Schools and Colleges
Senior College and University Commission and is an equal opportunity provider and employer.
ADMINISTRATION & FINANCE
Bursar Office
CREDIT CARD AUTHORIZATION FORM
One-time Recurring Cancellation
Schedule your payment to be automatically deducted from your Visa, MasterCard, American Express or Discover
Card.
How One Time Payments Work:
You authorize a one-time charge to your credit card.
How Recurring Payments Work:
You authorize monthly scheduled charges to your credit card.
Please complete the information below:
I, ______________________________ authorize the University of Guam to debit my credit card
Credit Card Holder’s Full Name
as indicated below for $______________ to start on the 30th of every month. Effective the
Amount
month of _____________________. This payment will credit _____________________________
Month and Year Student’s Name and ID#
for the following semester(s) ________________.
Ex: FA16/SP17
Total amount paid from scheduled payments $______________________.
Ex: $2,000.00
Phone# _________________________ Email ________________________________
Credit Card Account Information
Visa Master Amex Discover
Card Holder’s Name _____________________ Billing Address _____________________
Card Number _____________________ City, State, Zip _____________________
Expiration Date _________
A receipt for each payment will be emailed to you.
SIGNATURE DATE
I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify the University of Guam’s Bursar’s Office in writing of any changes
in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or
holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because
these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of a rejected
ACH Transaction or a denied credit card charge for Non-Sufficient Funds (NSF), I understand that UOG may at its discretion attempt to process the charge again
within 5 days, I agree to an additional $25.00 fee for each attempt returned NSF. This fee will be initiated as a separate transaction from the authorized recurring
payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user
of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to
the terms indicated in this authorization form.
Form 5001
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