Automatic Credit Card Monthly Deduction Form
IIT Four Month Plan

  Student Name:  
  Student SS# or SID#:  
  Student Email:  
  Cardholder Name:  
  Type of Credit Card:  
  Credit Card Number:  
  Expiration Date:  
  Academic Year:  
  Monthly Deduction Amount: $
     
  I hereby give the Illinois Institute of Technology, authorization to charge my credit card for the monthly payment amount listed above. I understand that this payment amount will be charged to my credit card each month, for the duration of the Four Month Payment Plan (Aug-2008 thru Nov-2008). I am also aware that it is my responsibility to notify IIT if the credit card number listed above changes or becomes invalid.
     
 
Cardholder Signature:
 ____________________________________________
     
 

Note: This form does NOT submit information online.
           Please remember to sign the form before you send it.


Deliver, fax or mail to the Bursar's Office:

IIT Bursar's Office
3300 South Federal
Main Building, Room 207
Chicago, IL 60616

Phone: 312-567-3785
Fax: 312-567-3325