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CASHIER’S OFFICE DEBIT/CREDIT CARD AUTHORIZATION FORM GEORGIA PIEDMONT TECHNICAL COLLEGE 495 North Indian Creek Drive Clarkston, GA 30021-2397 (404) 297-9522, ext. 1249 authorize Georgia Piedmont Technical College to charge my debit/credit card in the amount of $ NAME ON DEBIT/CREDIT CARD: BILLING ADDRESS OF CARDHOLDER: TYPE OF DEBIT/CREDIT CARD: American Express Is not accepted. DEBIT/CREDIT CARD NUMBER: 3 digit code located on the back of the card on the signature strip EXPIRATION DATE: (mm/yy) CARDHOLDER SIGNATURE: _____________________________________________ DAYTIME TELEPHONE NUMBER: STUDENT NAME: UPON COMPLETION OF THIS FORM PLEASE FAX IT TO 404-298-5235. AUTHORIZATION RECEIVED AFTER 3:00 PM MAY BE PROCESSED THE NEXT BUSINESS DAY. I, VISA MASTERCARD DISCOVER DATE: STUDENT ID NUMBER: SECURITY CODE:
