Credit Card Charge Authorization Form, ELI

University of Bridgeport
English Language Institute
126 Park Avenue
Bridgeport, Connecticut 06604
U.S.A.

I authorize the University of Bridgeport, English Language Institute to charge the amount shown below to my credit card. (Return by airmail or fax to 203 576-4861)

Name of cardholder (print exactly as it appears on the credit card)

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Circle one:  American Express      Mastercard      Visa

Credit card number

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Signature Code (last 3 digits of the number indicated on the back of your credit card)

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Expiration date (exactly as it appears on the credit card) ______________________

Total amount US $____________________

Signature of cardholder ___________________________________

Date __________/__________/__________
            month             day                year

Name of student (if other than cardholder) Please print 

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In payment for (circle as many as apply) 

Application fee; Tuition/Fees; Room; Security deposit; Insurance; Other:____________________