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:
601-403-1203
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