IEP Housing Credit Card Authorization Form

Please complete and return this form only if MasterCard or Visa is used to pay housing fees.


Name of Student: ___________________________________________________
(Last, First, Middle Initial)


Email Address: ___________________________________________________
(also specify name if not student)


CSUN Student I.D. Number: _________________________________________


I will use (check one): ___MasterCard     ___Visa


Credit Card Number: _______________________________________________


Expiration Date: ____________________


Amount of Charge*: $_________________


Name on Card (print): ______________________________________________


Card Holder's Signature: ____________________________________________


*PLEASE MAKE SURE THAT THE AMOUNT YOU ARE AUTHORIZING IS WITHIN THE CREDIT CARD AMOUNT LIMIT SO THAT PAYMENT IS NOT DECLINED.


Fax completed form to: