The College of Saint Rose
Credit Card Payment Form
Did you know that you can pay your student account online? To process a Discover, MasterCard, VISA, or
ACH (WebCheck) payment, log into your student account at https://bannerweb.strose.edu.
You may use this form to pay tuition, room, board and/or miscellaneous fees that have been billed to your
student account. You may also authorize a payment to increase your Golden Knights Kash balance.
Bring this payment form to the Student Solution Center (Saint Joseph Hall, 3
Mail form to: The College of Saint Rose, Bursar’s Office, 432 Western Ave. Albany, NY 12203
Fax form to: 518-454-2054
Note: For security purposes, please do not scan and email this completed form.
If you have any questions, please call the Bursar’s Office at 518-458-5464.
Credit Card Type:
Please check the appropriate option(s):
_____ I am authorizing payment for tuition, room, board and/or fees which have been billed to the account
of the student listed below. Please process payment in the amount of $______________
_____ I am authorizing payment in order to increase the Golden Knights Kash balance for the student
listed below. Please process payment in the amount of $________________
Student’s Name: ______________________________________________________
Student’s ID Number: __________________________________________________
Cardholder’s Name: ___________________________________________________
Credit Card Number: _________________________________ Exp Date: ________
Billing Street #: _______________________ Zip Code: _______________________
Daytime Phone #: ____________________________________________________
Cardholder’s Signature: _______________________________ Date: ___________
For Office Use Only:
Semester: Fall _________ Spring __________ Summer 1 __________ Summer 2 __________
Date Received: _______________ Received/Processed By: ________________