Credit Card Authorization Form - Texas
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 TxState ID#____________________________________
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_________________________________________
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) 245-6101 or (512) 245-1645
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