Credit Card Authorization Form Payment options include MasterCard, Visa, Discover and American Express, as well as bank checks and money orders. If you are using a debit card, the charge you are authorizing cannot exceed your daily withdrawal limit set by your bank. ________________________________________________ ______________________ Reservation for (First and Last name) Date of Birth __________/____________/_____________ (MM/DD/YYYY) Reservation arrival date _____________/______________/_________________ (MM/DD/YYYY) Reservation departure date I authorize Teachers College, Columbia University to charge my card in the amount of $_____________ for my Summer Housing deposit. Card Type (circle): Credit Debit Visa MasterCard Discover American Express ___/___ Exp. Date Card Number _____________________________________________ ____________________________________________________ (________ )__________________________________ Telephone Number _______________________________________________________________ Cardholder’s e-mail address Cardholder’s Name (print) Cardholder’s Signature _________________________________________________________________________________________________________________________________________________ Credit Card Billing Address ________________________________________________________________________________________________________________________________________________ After completing this form, email to (212) 678-3222 or e-mail to [email protected] If you do not provide us with the name of the guest this credit card should be applied to, this can result in a delay of your application.
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