Transcript Request Form - Kapiolani Community College Page 2
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1
2CREDIT CARD AUTHORIZATION FORM
(All fields must be completed)
Date: _________________
Fall ______
Spring ______
Summer ______
Student’s Name: ____________________________________________________________________________
Student’s UH ID Number: _____________________________________________________________________
I authorize the UNIVERSITY OF HAWAI‘I - KAPI‘OLANI COMMUNITY COLLEGE to use MY credit card to pay for:
Diploma Fee
Official Transcript Fee
Other: _____________________
VISA
MasterCard
JCB
Discover
Credit Card Type (check one):
Diners Club
Union Pay
BC
Total Amount to Be Charged: $ ____________________
Credit Card Number: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
Expiration Date: ___ ___ / ___ ___
Card Holder’s Card Code: ___ ___ ___
(Card code can be found in back of the credit card in the signature box.)
Card Holder’s Name: ________________________________________________________________________
Last Name, First Name, MI
Card Holder’s Billing Address: _________________________________________________________________
City: _______________________________________________ State: ________ Zip Code: ________________
Card Holder’s Phone Number: _________________________________________________________________
I agree to pay for the above fee according to the card issuer agreement. Note: If paying for an application
fee, by signing below you understand and acknowledge that the application fee is valid only for the
semester specified on the application and that the application fee is non-refundable and non-transferable.
Signature of Card Holder: _____________________________________________________________________
Mail, Scan/Email, or Fax the completed form to:
Kapi‘olani Community College – Kekaulike Center for Admissions, Records, Graduation & Financial Aid
4303 Diamond Head Road, ‘Ilima 102, Honolulu, HI 96816
Fax: (808) 734-9896 Phone: (808) 734-9555 Email: kapinfo@hawaii.edu
Office Use Only
Rev. 08/15
FO Hold: Yes/ No
Fee Posted By/Date _________________
Fee Paid By/Date _________________
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