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3.5% credit card processing fee applies to all credit card transactions

Credit Card

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Payment Amount *

Total Amount Being Charged:

1. Personal Information

Program Name*

Campus*

Student Name*

Address*

City*

State*

Zip Code*

Country*

Phone Number*

Alternate Phone

Email*

2. Payment Information

Cardholder First Name*

Cardholder Last Name*

Card Number*

Expiration Date*

CVV*

Check Number

Account Type*

Routing Number*

Re-enter Routing Number*

Account Number*

Re-enter Account Number*

* By authorizing this transaction, customer agrees that merchant may convert this transaction into an Electronic Funds Transfer (EFT) transaction or paper draft, and to debit this account for the amount of the transaction. Additionally, in the event this draft or EFT is returned unpaid, a service fee, as allowable by law, will be charged to this account via EFT or draft. In the event that I choose to revoke this authorization, I will do so by contacting the merchant directly. Processing times may not allow for revocation of this authorization. Processing electronic check payment using insufficient funds or incorrect account information, will result in a fee of .05% of the total amount, if it doesn’t exceed $7,499. The fee of 0.1% will be incurred for payments over $7,500.

First Name*

Last Name*

Additional Comments

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