Fillable Credit Card Payment Form printable pdf download

Credit Card Payment Form

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Credit Card Payment Form

(Off Campus Students Only)

If you wish to pay by credit card, please complete, sign, and mail or fax this form with your eBill to:

The George Washington University

Colonial Central Processing Unit

Marvin Center, Ground Floor

800 21

Street NW

Washington, DC 20052

(Tel) 202-994-6200

(Fax) 202-994-0578

For your security please Do NOT email this form.

If you must submit this form electronically, please email

CCProcessing@gwu.edu

for further instructions.

Name: _______________________________________________

GWid:

Work Phone: ___________________ Home Phone: ___________________ Semester: _____________________

 Visa

 MasterCard

Type of Card (MasterCard or Visa ONLY):

Email:___________________

Card Number:

Expiration Date (

MM/YYYY

Amount to be Paid by Credit Card: $ _______.___

Signature: __________________________________________ Date (

MM/DD/YYYY

__ __

__ __ __ __

Address: _________________________________

City & State: _______________ Zip Code: _____________

Note: Credit card payments are not accepted as payment for any on campus courses.

For Office Use Only:

Authorization No. _____________________ Reference No. ____________________________

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Credit Card Payment Form

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