Excel - Student Payment Form

Payment Type*

Single Course Purchase ($225 Ea. Please Indicate Class/s Below) Honors/CA: A-G ($325 Ea. Please Indicate Class/s Below) Pay Balance Owed Late Payment Credit Card Update - This Replaces Previous Card Number 60 Day Extension ($200) International Shipping Fee ($100 Flat Fee)) Replacement Graduation Packet ($59) (Includes: Congratulations letter, Official Sealed Transcript, Diploma and Diploma Padded Cover) Apostille Fee ($110) Adult Program - Regular Monthly Payment ($99.90) (Only applies to those with 0-4 declined transactions) Adult Program - 1 Late Payment ($109.90) Adult Program - 2 Consecutive Missed Payments ($209.80) Adult Re-enrollment Payment ($200 If Previously Completed Payments in Full) Other (Indicate In Additional Notes Below)

Choose All That Apply

Student Name *

First Name

Last Name

Student ID#

Leave Blank If You Do Not Know The #

Student Date of Birth (MM/DD/YYYY)*

Cardholder Name*

First Name

Last Name

Credit Card Number*

Credit Card Expiration: MM/YYYY *

Credit Card 3 -4 digit code*

Credit Card Billing Zip Code*

Submitting this form is not an automatic payment. The payment will be made manually within 3-5 days from submission.

$$$ - Amount To Be Charged*

A $10 late fee will be added to all late payments.

Sign with Mouse or Fingertip*

[clear]

Use your mouse or finger to draw your signature above

Mailing Address

Student Phone

Please Put International Phone Numbers In Additional Notes Below

Email (To Email Receipt)*

Additional Notes

If Purchasing Individual Class/s, List Here

Description Area