Credit Card Payment Authorization Letter
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1Form Ref. No.
FOR-FSD-2A
Version No.
2
Page
1 of 1
CREDIT CARD PAYMENT
CREDIT CARD PAYMENT
CREDIT CARD PAYMENT
CREDIT CARD PAYMENT AUTHORIZATION LETTER
AUTHORIZATION LETTER
AUTHORIZATION LETTER
AUTHORIZATION LETTER
FORM 2
FORM 2
FORM 2
FORM 2- - - - A A A A
Students who wish to pay via credit card through fax or e-mail, are requested to complete the details required
in this Credit Card Authorization Letter and fax the said letter to the University at Fax : + (60 85) 443971 or
email to
finance@curtin.edu.my
Please be reminded that no amendments are allowed in this Authorization Letter. Official Receipt will be
released by the University upon payment from the credit card company.
Dear Accounts Receivable, Financial Services Department,
CREDIT CARD PAYMENT AUTHORIZATION LETTER
I, ______________________________, hereby authorize Curtin University of Technology,
Sarawak Campus (owned and managed by Curtin (Malaysia) Sdn Bhd) to charge the
following amount to my credit card as follows for payment of :
Student Name
Student ID
Course Name
Semester No.
Total Amount (RM)
RM
Fee Breakdown as follows :
Course Fee Amount (RM)
Student Housing Fee Amount (RM)
Others – please specify below (RM)
The details of my credit card are as follows :
Name as appears on Credit Card: ____________________________________________
Card *
:
VISA / Mastercard
Card No
:
_ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ -_ _ _
(CVC** Number)
Card Expiry date
:
____ / ____
(mm / yy)
Yours sincerely
_______________________
(Signature as per card)
Date : __________________
*
Please delete where not applicable
** For credit card authorization through fax, a CVC number must be furnished. CVC number is the3 digit
validation code which is printed on the signature panel at the back of the card.
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