Fillable !Credt Card Authorization Form - Credt Card Authorization Form

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!Credt Card Authorization Form - Credt Card Authorization Form

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CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS
Police and Parking Services
One University Drive ♦ Camarillo CA 93012
(805) 437-8430 (P) ♦ (805) 437-8431 (F)
CREDIT CARD AUTHORIZATION FORM
Instructions for completing this form
FOR SECURITY OF YOUR CREDIT CARD DO NOT ATTEMPT TO ATTACH THIS FILE TO AN
E-MAIL!
• Fill in the Form
• SIGN THE FORM
• FAX to 805-437-8431 with a copy of the front and back of the credit card being used. Payments
will be processed within 48 hours. We will not notify you when the payment has been placed on
the account. Students may access their account through “My CSUCI”.
I hereby authorize California State University, Channel Islands (CSUCI) to charge the amount of $ _____________ to
my credit card indicated below:
Credit Card Type: MasterCard, Discover or American Express
Credit Card Number ________-________-________-_________ Exp Date: _______
Card Holder’s Name as printed on the credit card:
Address: ___________________________________________________
City:______________________________ State:_______ ZIP: ________________
Phone number where you can be reached: (_____) _______-______________
E-mail Address: _______________@_____________________________________
Student’s Name (if different from cardholder):
Student’s CSUCI ID No. ____________________________________ or
Social Security Number ____________ -_____ -____________
Card Holder’s Signature Authorization:
X ____________________________________________________
If you are notified that your credit card has been rejected for any reason, you must pay the amount shown above within
five (5) days. Payment may be made in person at Police and Parking Services, Monday thru Friday between the hours of
8:00 AM and 5:30 PM or mail your payment to CSU Channel Islands, Police and Parking Services, One University
Drive, Camarillo, CA 93012
For Official Use Approval Code: _______________
Date: _________________
Received By: ___________________
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Credt Card Authorization Form - Credt Card Authorization Form

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Completed 11 March 2020

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