JMU CARD SERVICES ON-CAMPUS APPLICATION

Send application to:

Card Services, 170 Bluestone Drive, MSC 3532, Harrisonburg, VA 22807

Or Fax completed form to (540) 568-1749

Student ID Number

Last Name, First Name, M.I.

For Office Use Only

________________________________________

Location Date Student Acct Code

Signature/Relationship - If other than student (signature required)

Declining Balance Accounts:

Please indicate deposit amount

FLEX

Dining Dollars Gold

METHOD OF PAYMENT:

Personal check [make payable to James Madison University]

VISA MasterCard Discover Other

CREDIT CARD NUMBER:
Expiration Date:
CID Number:

Billing Address (this is required for your application to be processed)

Signature of Credit Card Holder