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
for further instructions.
Name: _______________________________________________
Work Phone: ___________________ Home Phone: ___________________ Semester: _____________________
 Visa
 MasterCard
Type of Card (MasterCard or Visa ONLY):
Card Number:
Expiration Date (
Amount to be Paid by Credit Card: $ _______.___
Signature: __________________________________________ Date (
__ __
__ __
__ __ __ __
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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Parent category: Financial