Credit Card Authorization Form

Please fill out the information below and we will follow up

Card Type(Required)

Card Number(Required)

Expiration Date(Required)

LEAVE EMPTY

Cardholder's name(Required)

First Last

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cardholder's phone number(Required)

Amount to be charged (CAD)(Required)

3% Credit Card Surcharge(Required)

Total Amount to be charged (CAD)(Required)

Date(s) authorized to charge credit card payments. From:(Required)

To:(Required)

Full name of Student(Required)

First Last

I hereby authorize Braemar College to charge my credit card for the amount specified above.(Required)

YES

Date authorization provided(Required)