University of Lynchburg Campus Store
Credit/Debit Card Payment Authorization
Please complete and fax to the University Cashier’s Office 434.544.8658
Student’s Name _________________________________________
Student’s Date of Birth ______________
I hereby authorize University of Lynchburg to enter the following charges on my credit card as listed below:
- Monthly Hornet Account payments of $___________ or write BALANCE in the blank to have account balance charged on the 15th of each month. If BALANCE is written in, no finance charge or account hold will occur.
- Monthly Tuition payments of $______________to have payments made on 15th of each month.
- One-time Hornet Account deposit/payment of $___________.
- One-time Lynchburg Express deposit of $___________.
- One-time Tuition Account payment of $__________.
Please note: Each year you will need to submit this form a monthly payent option. If your card expires during the school year, you need resubmit this form to authorize future auto payments or call 434 544-8246 or 434 544-8217 or 434 544-8606 with new expiration date.
Name of card owner ______________________________________________________
Billing Address of the Credit Card _________________________________________________________________
Zip Code ___________
Phone # ___________________________(daytime)
• Type of card: ____ Visa ____ MasterCard ____ Discover
Account number ______________________________________________
Expiration Date _________________ Security Code on back of card________
Authorized Signature ________________________________
Print this form out and fax to 434.544.8658.
* Please note that any unpaid miscellaneous items will be charged to your credit card with your final payment in June of each year for non-seniors, and on April 15 for seniors.