Credit Card Payment Authorization
International Programs
Studen
t ID# 8449__________________________ Date of Birth (MM/DD/YY)_______________ Date:________________
Student Last Name: ______________________________ First Name: _________________________________________
Name as it appears on the card: ________________________________________________________________________
Cardholder’s Address: ________________________________________________________________________________
City: ________________________________________ Country: ______________________________________________
Visa: MasterCard: Discover: Credit Card #:___________________________________Expiration ____/____
Quarter to apply charges to (Select one): Fall Winter Spring Summer 20____
Applicable Charges:
Charg
e Check Appropriate Boxes Cashiering Code Amount
Application Fee - $50 I8 $
Homestay Placement Fee - $300 IH/IZ $
Campus Corner Placement Fee - $300 IS/IK/IZ $
Prepaid Tuition & Fees IP $
Campus Corner Rent IR $
Other $
Total Deposit $
As a card holder, or as a representative of the card holder noted above, I hereby authorize the charges as note.
Signature:_______________________________________________Date:____________________________________
From:__________________________________________________Fax#:_____________________________________
Scan and email to: international@greenriver.edu
Or fax to: +1 (253) 333-4940
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