Credit Card Authorization Form - TC-CMS

Credit Card Authorization Form
Payment options include MasterCard, Visa, Discover and American Express, as well as bank checks and money
orders. If you are using a debit card, the charge you are authorizing cannot exceed your daily withdrawal limit
set by your bank.
________________________________________________
______________________
Reservation for (First and Last name)
Date of Birth
__________/____________/_____________ (MM/DD/YYYY)
Reservation arrival date
_____________/______________/_________________ (MM/DD/YYYY)
Reservation departure date
I authorize Teachers College, Columbia University to charge my card in the amount of $_____________ for my
Summer Housing deposit.
Card Type (circle): Credit Debit
Visa
MasterCard Discover  American Express
___/___
Exp. Date
Card Number
_____________________________________________
____________________________________________________
(________ )__________________________________
Telephone Number
_______________________________________________________________
Cardholder’s e-mail address
Cardholder’s Name (print)
Cardholder’s Signature
_________________________________________________________________________________________________________________________________________________
Credit Card Billing Address
________________________________________________________________________________________________________________________________________________
After completing this form, email to (212) 678-3222 or e-mail to daw2180@tc.columbia.edu
If you do not provide us with the name of the guest this credit card should be applied to, this can
result in a delay of your application.