Faculty of Extension

Credit Card Permission Form

Date: _________________

To Whom It May Concern:

Please be advised that I, _____________________________________________________________ give

authorization to the University of Alberta English Language School to use my credit card to
pay for my tuition and related student fees at the University of Alberta.

The total amount that can be charged against my credit card is $____________________

The name on face of credit card is: ____________________________________________________

My Credit Card Number is: _________-_________-_________-_________

My Credit Card Expiry Date is: _______/_______

Cardholder Signature: _____________________________________