Special Collections and Archives Department, Cline Library, NAU
CREDIT CARD PAYMENT FORM
Complete and mail or fax this form with your order to:
Special Collections and Archives Department
Cline Library, Northern Arizona University, PO Box 6022
Flagstaff, AZ 86004   *   Phone (928) 523-5551   *   Fax (928) 523-3770
Today's Date				Order ID (office use only)
				Expiration Date:
Credit Card Number					Month	Year
Type of Card (choose one):
Mastercard	Visa			Total Amount to Be Paid
Name of Credit
Card Holder (PRINT):
as it appears on card	First		Middle		Last
Address of Credit Card Holder:
						Apt/Lot #
		City		State		Zip
(          )
Phone Number of Credit Card Holder				Credit Card Holder Signature		Date
Authorization Code:
Patron Order Information
		Patron Address:
Patron Name (PRINT)						Apt/Lot#
(          )
Daytime Phone Number				City	State	Zip
Affiliated Organization
Brief Description of Order:
Other: