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PRIME Business Dining
Declining Balance Plan
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Name
*
First
Last
Email
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Student or Staff:
*
Choose One
Student
Staff
HVCC ID:
*
Add Additional Dollars
*
Select the dollar amount you wish to add
Add $1.00
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Add $900.00
Add $1000.00
Total Amount
$ 0.00
Authorization
*
I authorize Mazzone Hospitality to charge my credit card for this declining balance deposit.
I authorize Mazzone Hospitality to charge my credit card for this declining balance deposit. Charge will appear on credit card statement as "Glen Sanders Mansion". I understand declining balance funds are non-refundable. All unused dollars at the end of the Summer Semester are forfeited.
I Understand
*
I understand that this is my agreement with Mazzone Hospitality for enrollment in the Declining Balance Plan.
I understand that this is my agreement with Mazzone Hospitality for enrollment in the Declining Balance Plan and that I may make additional deposits at any time in the future.
Credit Card Information
*
Card Number
MM
1
2
3
4
5
6
7
8
9
10
11
12
Expiration
/
YY
24
25
26
27
28
29
30
31
32
33
34
Security Code
Name on Card
*
First
Last
Billing Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
*Please allow 24-48 hours for funds to be credited to your account.
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