Amount to be charged to my credit card as payment for tuition and
fees and/or other debts: $___________

(Please print)

Student's Name _________________________________________

Student's I.D. Number _______-_____-_______

Cardholder's Name________________________________________

Cardholder's Address______________________________________

_______________________________________________________

Credit Card Number ____________________________

VISA______ MC ______Discover______ American Express______

Expiration Date __________

Cardholder's Signature______________________________________

E-Mail Address ____________________________________

Daytime Phone Number (_____)_______-_________