Credit Card Payment Form
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1Credit Card Payment Form
You may use your VISA®, Mastercard®, or American Express® card to pay Athabasca
Financial Services, Athabasca University
University fees.
1 University Drive, Athabasca,
9
3
3
AB T
S
A
Toll Free in Canada/
: 1.800.788.9041
US
Other: 780.675.6111, Fax: 780.675.6174
Payment
Name:
_____________________________________________
STUDENT ID NUMBER (if applicable)
(please print)
Address:
_____________________________________________
_____________________________________________________________________
POSTAL/ZIP CODE
_________________________________________
®
r MasterCard®
r
VISA
_____________________________________
_________ / _________
r
®
AMERICAN EXPRESS
EXPIRY DATE
DESCRIPTION
AMOUNT CHARGED
(e.g., application fee or course name and number )
Where incorrect fees are
The personal information collected on this form will be used for the purpose of pro-
cessing payments. This personal information is being collected under the authority
listed, Athabasca University
of Section 33(c) of Alberta’s Freedom of Information and Protection of Privacy Act. If
will automatically
you have any questions about the collection and use of this information, contact
charge your account with
the Senior Accountant, Athabasca University, 1 University Drive, Athabasca, Alberta,
the correct amount.
9
3
3, Phone: 800.788.9041.
T
S
A
TOTAL
Signature:
____________________________________________ Date: __________________
Payment
Name:
_____________________________________________
STUDENT ID NUMBER (if applicable)
(please print)
Address:
_____________________________________________
_____________________________________________________________________
POSTAL/ZIP CODE
_________________________________________
®
r MasterCard®
r
VISA
_____________________________________
_________ / _________
r
®
AMERICAN EXPRESS
EXPIRY DATE
DESCRIPTION
AMOUNT CHARGED
(e.g., application fee or course name and number )
Where incorrect fees are
The personal information collected on this form will be used for the purpose of pro-
cessing payments. This personal information is being collected under the authority
listed, Athabasca University
of Section 33(c) of Alberta’s Freedom of Information and Protection of Privacy Act. If
will automatically
you have any questions about the collection and use of this information, contact
charge your account with
the Senior Accountant, Athabasca University, 1 University Drive, Athabasca, Alberta,
the correct amount.
9
3
3, Phone: 800.788.9041.
T
S
A
TOTAL
Signature:
____________________________________________ Date: __________________
Payment
Name:
_____________________________________________
STUDENT ID NUMBER (if applicable)
(please print)
Address:
_____________________________________________
_____________________________________________________________________
POSTAL/ZIP CODE
_________________________________________
®
r MasterCard®
r
VISA
_____________________________________
_________ / _________
r
®
AMERICAN EXPRESS
EXPIRY DATE
DESCRIPTION
AMOUNT CHARGED
(e.g., application fee or course name and number )
Where incorrect fees are
The personal information collected on this form will be used for the purpose of pro-
cessing payments. This personal information is being collected under the authority
listed, Athabasca University
of Section 33(c) of Alberta’s Freedom of Information and Protection of Privacy Act. If
will automatically
you have any questions about the collection and use of this information, contact
charge your account with
the Senior Accountant, Athabasca University, 1 University Drive, Athabasca, Alberta,
the correct amount.
9
3
3, Phone: 800.788.9041.
T
S
A
TOTAL
Signature:
____________________________________________ Date: __________________
Jan 2014
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Parent category: Financial