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Credit card authorization form

We accept VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER.

I hereby authorize CSUEB to debit my _________________________________ card: Account Number: Expiration date:

__________ __________ Month Year

Amount:

$______________________________________

Name on card:

_______________________________________

Purpose:

_______________________________________

Billing address:

_______________________________________ ________________________________________ ________________________________________ _____________________________________

Signature:

_____________________________________

Date:

_____________________________________

  California State University Eastbay  

American Language Program 25800 Carlos Bee Blvd Hayward, CA  94542‐3012  Phone: 510‐885‐7518  Email: ielts@csueastbay.edu

Credit Card Authorization Confirmation  
Credit Card Authorization Confirmation  

ورقة تأكيد الطلب لمدينة هايورد...ورقة الدفع

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