Northwestern Caribbean Baptist Theological Seminary

Northwestern Caribbean Baptist Theological Seminary
ONE (1) TIME CREDIT CARD AUTHORIZATION
By signing this form, you give us permission to charge your credit card for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.
I, (cardholder) authorize
Cayman Islands Baptist (Merchant Name) to charge my credit card or debit card
(as indicated below) for US$
on (date)
This payment is for the following (course detail)
BILLING INFORMATION
Address

Billing Address

Street Address Line 2

City, State, ZIP
Phone #
Email
example@example.com
Credit Card Type

Mastercard I VISA I Discover I AMEX I Other
or:

Debit card USD or KYD CREDIT / DEBIT CARD INFORMATION
Card Number (#)
Expiration (MM/YY)
CVV Code(3 digits)
CARDHOLDER SIGNATURE
I authorize the above named merchant to charge the credit card or debit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one (1) use only. I certify that I am an authorized user of this credit card or debit card and that I will not dispute the payment with my credit card/debit card company; so long as the transaction corresponds to the terms indicated in this form.
Cardholder Signature

Clear
Date

Month Day Year
Date
Cardholder Name
Should be Empty: