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Credit Card Payment Authorization Form
Sign and complete this form to authorize Breyer State Theology University to collect payment(s) to your credit card listed below.
By signing this form you give us permission to debit your account for the amount indicated on or after the indicated dates(s) . This is permission for the listed transaction(s) only, and does not provide authorization for any additional unrelated debits or credits to your account.
Please complete the information below :
I authorize the above named BSTU to charge the credit card indicated in this authorization form according to terms outlined above . This payment authorization is for the good/services described above, for the amount indicated above 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.