Credit Card Payment Form printable pdf download

Credit Card Payment Form

University of Maryland Baltimore County

Albin O. Kuhn Library & Gallery

Interlibrary Loan Department

1000 Hilltop Circle

Baltimore, MD 21250

E-Mail:

illcm@umbc.edu

Telephone: (410) 455-2234

Fax: (410) 455-1061

CREDIT CARD PAYMENT FORM

Date:

____________________________

Agency Name:

____________________________

Contact Name:

_____________________________

Address:

_____________________________

Invoice Number:

____________ ILL/TN Number __________________

Payment Amount:

_____________________________

Description of Payment: ___________________________

Cardholder Name: __________________________ Phone: ______________________

E-Mail Address:

_______________________

Fax: _______________________

□

Charge to:

MasterCard

Visa

Discover

American Express

Credit Card No: ______________________________

Expiration Date: _____________________________

Signature: __________________________________

Cardholder

Note: You may mail, fax, or attach this document to email. If you choose not to fax the credit card number,

you may fax the signed form and call us to complete the transaction.

Credit Card Payment Form