Credit Card Authorization Form

Cashiering and Student Accounts

UNLV

Fax # (702) 895-1164

Please type or print in BLACK ink

Student's Name_________________________________________________________

Student 's ID# __________________________________________________________

Student 's Home Address_________________________________________________

Credit Card (please circle one)

VISA MASTERCARD DISCOVER AMERICAN EXPRESS DINERS CLUB

Card Number________________________________________________

Expiration Date_______/_________

Name (as printed on card)______________________________________

Card Holder's Address_________________________________________

Phone Number_________________________

I authorize the use of the above listed credit card to pay the fees listed below to the University of Nevada, Las Vegas. I understand that the credit card transaction will occur on the transaction date listed above for the amount I have indicated. I understand that fee payment deadlines, and/or late fees are my responsibility. I further understand that I may be charged a penalty fee if the credit card company denies my credit card. I understand that a facsimile or photocopy of this form with my signature on it is the same as an original. Please ensure that you complete this form in its entirety.

AMOUNT

$____________ TUITION

Card Holder’s Signature___________________________________ Date____________