Winthrop University
Credit Card Payment Authorization

Name/Company Name:


Federal Tax Identification Number:
  □  Visa   □  MasterCard   □  Discover Card Amount: $
Account Number: Expiration Date:
Cardholder Name:


Cardholder Address:


Cardholder Phone No: Fax:
City: State: Zip:
The issuer of the card identified on this item is authorized to pay the total (together with any other charges due thereon) subject to and in accordance with the agreement governing the use of such card.
Cardholder Signature: Date: