CREDIT CARD AUTHORIZATION FORM
INSTRUCTIONS:
1. Complete form with credit card billing information.
2. Sign where indicated.
3. A copy of the front and back of an unexpired photo ID is to be submitted with this form to the Student Accounts
Office either in person, via fax, or by mail.
MAIL: ASA College IN PERSON: Room 409
One Herald Center
New York, NY 10001
ATTN: Student Accounts Department FAX: (212) 672-0370
*Denotes required fields:
*Date:
*In reference to:
(Student’s Name & ID Number)
*Cardholder Name:
*Credit Card: Visa
MasterCard
American Express
*Card Number:
*CVV Code:
*Expiration
Date:
*Billing Address:
*Email Address:
I authorize ASA College to charge my credit card in the amount of $ _________________ on the (check one):
15
th
or 30
th
of each month until my student account is paid in full.
*Print Name:
Date:
*Signature:
Date:
click to sign
signature
click to edit
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