Pre-Authorization Form
All information will remain confidential
*
Required
Event Title
:
*
:
Please select
CASC | Application Fee $200
First Name:
*
Last Name:
*
Event Contact:
*
Start Date:
End Date:
Credit Card Holder Information
First Name
:
*
:
Last Name:
*
Email Address
*
:
I hereby authorize the San Diego County Office of Education to charge my credit card for the following amount(s):
Total Amount:
$
Pay in Installments:
Yes
No
No. of Installments:
3
4
Billing address on credit card:
Address:
*
City:
*
State:
*
Zip Code:
*
:
Phone Number:
*
Card Type:
*
-Select-
American Express
Discover
MasterCard
Visa
Card Number:
*
Card Expiry:
*
Month:
-Select-
January
February
March
April
May
June
July
August
September
October
November
December
Year:
-Select-
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
CVV:
*
If you have any questions with completing this form, please contact
at:
.