Manager of Quality Assurance, Student Accommodations

400 Alexander Park

Princeton, New Jersey 08540 USA
Telephone: (609) 750-3500
FAX: (609) 514-9674
e-mail: arafailovic@els.edu

CREDIT CARD AUTHORIZATION FORM

NAME:

___________________/____________________
(FAMILY NAME)

(FIRST NAME)

I authorize ELS Language Centers to charge my credit card as indicated below and I agree to be bound by the ELS
Language Centers cancellation and refund policies as outlined on the ELS application form.
DATE: _____________________________________

NAME (as it appears on card): ____________________________________________________

(FIRST NAME)

(FAMILY NAME)

CARDHOLDERS RELATIONSHIP TO STUDENT: __________________________________

TYPE OF CARD:

_____ VISA
_____ MASTERCARD
_____ JCB

_____ AMERICAN EXPRESS

_____ DINERS CLUB

CARD NUMBER: ________________________________________________

EXPIRATION DATE: ________/_________

(month)

VERIFICATION#_____________________

(year)

AMOUNT TO BE CHARGED: US$ ________________

CARD HOLDERS SIGNATURE: _____________________________________

CARDHOLDERS BILLING ADDRESS: _____________________________________________
_____________________________________________
PLEASE ATTACH A PHOTOCOPY OF THE FRONT AND BACK OF THE CREDIT CARD TO THIS
SHEET.