College in the High School Credit Card Payment
(Attach to registration form)
NAME OF STUDENT STUDENT’S SOCIAL SECURITY NUMBER
NAME OF CARDHOLDER
CARDHOLDER’S ADDRESS CITY ST ZIP
PHONE: (DAY) (EVENING)
Paying by: VISA M/C Discover (Only Visa, Mastercard or Discover cards are accepted)
Authorized Amount: ______________
Card # ___________________________________________________________________________ Exp. Date: ____________
Name as it appears on card: ________________________________________________________ V-code *: _______________
The V-code is the last 3 digits of the number located on the back of your Visa/MasterCard. Banks now require the V-code in order to process your credit card. This
new policy has been implemented in response to the increasing threat of credit card fraud. This policy is in place to protect you!
This document will be promptly shredded after payment has been processed.
Each 5-credit College in the High School course is $180.00.