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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:

_____________________________________

CaliforniaStateUniversityEastbay

American Language Program

25800CarlosBeeBlvd
Hayward,CA
945423012
Phone:5108857518
Email:ielts@csueastbay.edu