Credit Card Authorization Form

Student Name _________________________________________

DOB _________________________________________

Program _________________________________________

Credit Card Number _________________________________________

Name on Card _________________________________________

Card Type _________________________________________

Expiry Date _________________________________________

CVV Code _________________________________________

I hereby authorize Cape Breton University to charge the following amount to my

credit card on behalf of myself or for the following students –

Student Name Amount

________________________________________ ___________

________________________________________ ___________

________________________________________ ___________

________________________________________ ___________

Signature _______________________ Date ____________