Date:____________
Graduation Application
Credit/Debit Card Authorization Form
Student Information:
Name: ___________________________________________________________ Student ID#: _________________________
(Last) (First) (M.I.)
Address: ______________________________________________________________________________________________________________
Phone Number: (________) _____________________________ Email: ________________________________ @hawaii.edu
Cardholder Information:
Name: __________________________________________________________
(As Printed on Card)
Billing Address: ______________________________________________________________________________________________________
Card Issuer: Visa MasterCard
Credit/Debit Card Number (16-Digits): _______________________________________
Expiration Date: ________________
Card CV2 Code (3-digit code on back of card): _____________ Amount: $ __________________
PLEASE MAIL OR FAX THIS FORM WITH GRADUATION APPLICATION TO:
UNIVERSITY OF HAWAI`I AT HILO
OFFICE OF THE REGISTRAR
200 W. KAWILI STREET
HILO, HAWAII 96720
FAX: (808) 932-7448
To Student:
•
This form may be used when paying for the Graduation Application processing fee by credit or
debit card
• Do not use this form if you are paying with a check or money order
• Non-refundable fees (subject to change): $15.00 Graduation Application Processing Fee (per
degree, certificate, or additional diploma)
•
This form is to be accompanied by your graduation application
I agree to pay the non-refundable fees that are indicated on the graduation application.
Cardholder Signature: _______________________________________________________________ Date: ____________________
