NORTHAMPTON COMMUNITY COLLEGE
GIFT CERTIFICATE ORDER
Please fill out completely and print clearly. Complete information is required to ensure accurate
processing.
Purchaser Name
Last
First
Middle
Billing Address _______________________________________________________________________
_______________________________________________________________________
City
State
Zip
Phone Number Day (_______)_____________________
Evening (_______)_________________
(Please include a telephone number in the event we need to reach you regarding your payment)
Gift Certificate Order Information:
Quantity
__________
Amount
$_______________
__________
$_______________
__________
$_______________
‰ Check Enclosed
Total Amount Enclosed $_____________
Card Type (check one)
‰ MasterCard
‰
Discover
‰ Visa
‰ American Express
‰Charge Amount $ ________________
‰Charge balance due in full
3 Digit Security Code ___________
Card Account Number
Expiration Date _______/________
Cardholder Name___________________________ Signature __________________________
(Please Print)
Authorized Cardholder Only
_
Cardholder Billing Address*
*Address on file with
Your credit card company
Street (no PO Box) Apt #
Cardholder Telephone Number (
City
State
Zip
)
(Please include a telephone number in the event we need to reach you regarding your payment)
¾
Your check or credit card statement will be your receipt. Please do not mail cash.
¾
Mail completed form to:
¾
¾
Bursar’s Office, Northampton Community College,
3835 Green Pond Road, Bethlehem, PA 18020
-ORFax completed form to:
610-861-5551 (Fax machine is located in a secure location)
-OROr drop your check or credit card payment in our secured drop box. The drop box door is located
outside the Main Campus Student Enrollment Center to the right of the building’s main entrance.
NCC is not responsible for cash dropped in the drop box.
Your gift certificate(s) will be mailed to the address above. Northampton Community College is not
responsible for lost or stolen gift certificates.