2016 Credit Card Payment Form Master Card

Visa

American Express

Amount to be charged: $ Card#:

Exp. Date:

Credit Card Billing Address: Zip Code: Name as it appears on card: Telephone: Employer/Institution Name: Signature: __________________________________

Date: ________________

You may fax the completed form to 336-334-7018 or mail it to the following: North Carolina A&T State University Office of Career Services Attn: Denise Burston 1601 E. Market Street Murphy Hall, Suite 101 Greensboro, NC 27411 NORTH CAROLINA A&T STATE UNIVERSITY (REV 11.15)