CC Authorization – STG Travel

One Time Credit Card Payment Authorization Form

Please complete this form to authorize STG Travel Inc to make a one time debit to your credit card listed below.

By completing this form you give us permission to debit your account for the amount indicated (including a non-refundable 5% CC Surcharge Fee) on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

CC Authorization

School *

or description of goods/services

Amount

5% CC Surcharge

Total to be charged to Card

Charge on or after Date *

Billing Information

Cardholder Name (as shown on card) *

First

Last *

Last

Billing Address *

Billing Address

Street Address

Apt./Building/Suite #

City

State/Province

Zip/Postal

Country

Credit Card Information

Card Type *

Credit Card Number *

Credit Card Number

Credit Card Information *

Credit Card Number

Expiration Date *

CVV Code *

Authorization *

By checking this box I authorize STG Travel, Inc. to charge the credit card indicated above according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Authorization *

By checking this box I agree to a non-refundable 5% CC Surcharge Fee

reCAPTCHA