Pearl River Community College
Printable Credit Card Payment Authorization Form
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Dear Customer:
For your convenience, we accept VISA and MasterCard.  Please indicate method of payment below:

VISA/MasterCard |__|__|__|__|X|__|__|__|__|X|__|__|__|__|X|__|__|__|__| 

Expiration Date (MM/YY) |__|  |__|

Student's Social Security Number |__|__|__|X|__|__|X|__|__|__|__|

Amount $$$  |__|__|__|__|.|__|__|

Zip Code |__|__|__|__|__|
 

Signature_______________________________________

Date __________________________________________


 
 
Mail to:
PRCC
P.O. Box 5060
Poplarville, MS  39470
Fax to:
601-403-1366