CREDIT CARD PAYMENT FORM Professional Development The University of Texas at Brownsville

Professional Development
The University of Texas at Brownsville
Advanced Placement Summer Institute
CREDIT CARD PAYMENT FORM
STUDENT INFORMATION
Student ID #:
First Name:
Last Name:
Address:
M.I.:
City:
Home Phone :
Zip Code:
State:
Mobile Phone:
(Ex. 9568828200 - PDF will re-format the number.)
E-mail:
PAYMENT METHOD
Name on Credit Card:
(If different from Student's Name)
Billing Address:
Type of Credit Card:
MasterCard
Amount to Charge:
Visa
Credit Card Number:
Expiration Date (MM/YY):
PAYMENT FOR
Course Fee
Course Name:
Credit Card Holder's Signature:
Date:
IMPORTANT NOTICE - BEFORE FAXING PLEASE ...
Ensure that a MasterCard/Visa Account Number and Expiration Date are
included along with a phone number where you may be reached.
Fax Number:956-882-4171
Print Form
301 Mexico Blvd. • Suite D3A-102 • Brownsville, TX 78520 • 956-882-4160 • 956-882-4171 • utb.edu/edcs