Office of the Bursar

Credit Card Payment Form

• Please use this form to pay for tuition, housing and accounts receivable charges using a Visa or Mastercard.
• You can also print off this form and fax it to 1-928-523-0009 or call us over the phone at 1-928-523-1122.
• If paying from a billing statement, please fill in the correct amounts on the form below.
• If paying only for a certain accounts receivable charge, i.e. a particular parking ticket, please tell us so in the "Special Instructions" box below.
• If the total authorized* is more than currently owed, we will adjust the payment downward. We cannot adjust the payment upward.
• Incomplete information or insufficient credit will result in cancellation of the transaction.
• Please allow 2 business days for payment to post to the system.
• We accept tuition, housing, and accounts receivable payments; such as parking tickets. To add money to your Mountain Campus Express Card (MCEC), go to: http://www.nau.edu/naucard/mcegate.html. Sorry, we cannot accept Flexi, meal ticket or library payments.
• Any refund due from this transaction will result in a check made out to the student.
  We cannot refund back to the credit card.
• Please verify that all input information is correct with special attention paid to the credit card number.
• Do not submit multiple requests for the same payment. Please call (928) 523-1122 if you have a question regarding the receipt of your internet payment.
• This transaction uses industry standard SSL and PGP encryption technology.

Student's E-Mail Address:
Student's Full Name:
Student's ID#:
Credit Card Type:	Visa Mastercard
Credit Card Number:
Expiration Date (mm/yy):
Cardholder's Name:
Cardholder or Sender's E-mail Address: (We must have your return e-mail address.)
Contact's Daytime Phone (###)###-####:
Tuition Amount $:
Registration Fees $:
Housing/Dorm Amount $:
Housing Application Fee $:
Accounts Receivable (A/R) Amount $: (Parking Tickets, etc.)
*Total (from above) authorized to charge to your credit card $:
If paying a particular A/R charge above, please specify below:

Submitting this request does not authorize the card for payment.  We will manually process your request for approval.  The confirmation page does not guarantee the card was authorized for payment.  We will notify you if the card is declined.

After sending payment request, please print the confirmation page as your receipt.