Trinity Valley Community College
**One Time ONLY Authorization**
for Debit/Credit Card Payment
I, ________________________________________________,
authorize TVCC to charge my: (check one)
______ MasterCard
______ Visa
______ Discover
on the following card number
_____________-_____________-____________-____________,
Exp. Date (________/_________),
Security Code (found on back of card) ________________,
for the following amount $____________________________.
Student’s name: ______________________________________
Student’s TVIN #: ____________________________________
Semester/Year: __________ Purpose: ___________________
Print cardholder’s name:
_________________________________________
Cardholder’s signature:
____________________________________________
Date: ____________________________________________
Daytime phone #: ________________________________
Date of birth of cardholder: _______________________
Cardholder’s billing address:
__________________________________________________
__________________________________________________
__________________________________________________
Please fax completed form to: (903) 675-6270