Credit Card Authorization Form

To be used ONLY for the payment of permits and ticket fees.

Student’s Name________________________________________________

Student’s Address_______________________________________________

City___________________________ State_____________ Zip__________

Student’s Phone Number_________________________________________

Student’s SSN or TxState PLID____________________________________

Circle Credit Card to be used

VISA MASTERCARD

AMERICAN EXPRESS DISCOVER

Credit Card No._______________________ ________ Exp. Date_______

Printed Name of Cardholder_____________________________________

Phone Number of Cardholder____________________________________

Zip Code of Cardholder_________________________________________

CVC Code (three digit number located on the back of card) _____________________

I authorize that the above referenced Credit Card be charged the amount of

$________________ for the payment of permit(s) and parking ticket(s).

_______________________________________ _______________

Signature Date

Return via Fax (512) 245-1645