DIVISION OF CONTINUING EDUCATION
CREDIT CARD AUTHORIZATION
I, do hereby agree for
Wilson Community College to charge my Debit/Credit Card in the amount of $ .
STUDENT INFORMATION
First Name: Initial: Last Name:
Student ID Number or SSN:
DEBIT/CREDIT CARD INFORMATION
Name on Card:
Type of Card:
q Visa q Mastercard q Discover
Card Number: Expiration Date: Amount: $
Daytime Phone Number:
3-Digit CCVN Security Code:
To provide the CCVN (Credit Card Verification Number) 3-digit security number, look on the back of
your card and use the last 3 digits of the number printed inside the box where you signed your name.
Receipt Requested: q Yes q No
Mail Receipt to - Name:
Address:
City: State: Zip:
Card Holder’s Signature: Date:
Fax this information to:
Wilson Community College, Attn: Continuing Education
Fax Number: (252) 243-7148
Any questions, please call:
Kay Medlin – (252) 246-1317 or Lois McNeal – (252) 246-1287
